Provider Demographics
NPI:1558877282
Name:DREGELY, VIVIAN
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:
Last Name:DREGELY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1541 SILVERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90041-3124
Mailing Address - Country:US
Mailing Address - Phone:212-470-7064
Mailing Address - Fax:
Practice Address - Street 1:1541 SILVERWOOD DR
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90041-3124
Practice Address - Country:US
Practice Address - Phone:212-470-7064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-18
Last Update Date:2021-04-15
Deactivation Date:2021-03-14
Deactivation Code:
Reactivation Date:2021-04-12
Provider Licenses
StateLicense IDTaxonomies
CA124829106H00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician