Provider Demographics
NPI:1619474517
Name:DE LA VEGA, OMAR (AMFT, APCC)
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:DE LA VEGA
Suffix:
Gender:M
Credentials:AMFT, APCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 LORELLA AVE
Mailing Address - Street 2:
Mailing Address - City:LA HABRA
Mailing Address - State:CA
Mailing Address - Zip Code:90631-5218
Mailing Address - Country:US
Mailing Address - Phone:562-665-3877
Mailing Address - Fax:
Practice Address - Street 1:1940 E DEERE AVE STE 100
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-5718
Practice Address - Country:US
Practice Address - Phone:714-543-4333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-09
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104615106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist