Provider Demographics
NPI:1710472501
Name:VEGA, KEREN (LICENCIADA)
Entity Type:Individual
Prefix:MISS
First Name:KEREN
Middle Name:
Last Name:VEGA
Suffix:
Gender:F
Credentials:LICENCIADA
Other - Prefix:MISS
Other - First Name:KEREN
Other - Middle Name:
Other - Last Name:VEGA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:8516 CALLE LA CEIBA
Mailing Address - Street 2:
Mailing Address - City:QUEBRADILLAS
Mailing Address - State:PR
Mailing Address - Zip Code:00678-9725
Mailing Address - Country:US
Mailing Address - Phone:787-895-7915
Mailing Address - Fax:
Practice Address - Street 1:CARR 2 KM 101.5
Practice Address - Street 2:TERRANOVA
Practice Address - City:QUEBRADILLAS
Practice Address - State:PR
Practice Address - Zip Code:00678
Practice Address - Country:US
Practice Address - Phone:787-895-7915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-25
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6155101YM0800X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health