Provider Demographics
NPI:1750034559
Name:VARGAS, ANTOINETTE ALEXANDRIA
Entity Type:Individual
Prefix:MRS
First Name:ANTOINETTE
Middle Name:ALEXANDRIA
Last Name:VARGAS
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 1:3584 FAIRLANES AVE SW STE 2
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-1583
Mailing Address - Country:US
Mailing Address - Phone:616-222-5300
Mailing Address - Fax:616-222-5309
Practice Address - Street 1:3584 FAIRLANES AVE SW STE 2
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-1583
Practice Address - Country:US
Practice Address - Phone:616-222-5300
Practice Address - Fax:616-222-5309
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-01
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851114979104100000X
MI171M00000X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator