Provider Demographics
NPI:1558972877
Name:GONZALEZ VEGA, ANGELICA M (MS)
Entity Type:Individual
Prefix:
First Name:ANGELICA
Middle Name:M
Last Name:GONZALEZ VEGA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1720
Mailing Address - Street 2:
Mailing Address - City:ANASCO
Mailing Address - State:PR
Mailing Address - Zip Code:00610-1720
Mailing Address - Country:US
Mailing Address - Phone:787-503-2484
Mailing Address - Fax:
Practice Address - Street 1:CARR 106 KM 5.1 INT BO QUEMADO
Practice Address - Street 2:
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680
Practice Address - Country:US
Practice Address - Phone:787-503-2484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-11
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6365103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist