Provider Demographics
NPI:1659680288
Name:VEGA, ANASTASIA E (SAC-IT)
Entity Type:Individual
Prefix:
First Name:ANASTASIA
Middle Name:E
Last Name:VEGA
Suffix:
Gender:F
Credentials:SAC-IT
Other - Prefix:
Other - First Name:ANASTASIA
Other - Middle Name:E
Other - Last Name:NEDD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SAC-IT
Mailing Address - Street 1:285 N JANACEK RD
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-6102
Mailing Address - Country:US
Mailing Address - Phone:262-641-9050
Mailing Address - Fax:262-641-9126
Practice Address - Street 1:6416 S HOWELL AVE
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-1104
Practice Address - Country:US
Practice Address - Phone:414-762-5429
Practice Address - Fax:414-762-9727
Is Sole Proprietor?:No
Enumeration Date:2010-09-30
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15636-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)