Provider Demographics
NPI:1508329079
Name:VEGA, BENJAMIN
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:VEGA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7060 SW MOLALLA BEND RD
Mailing Address - Street 2:
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-8450
Mailing Address - Country:US
Mailing Address - Phone:805-804-0689
Mailing Address - Fax:
Practice Address - Street 1:29174 SW TOWN CENTER LOOP W STE 101
Practice Address - Street 2:
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-9309
Practice Address - Country:US
Practice Address - Phone:971-252-6155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-10
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst