Provider Demographics
NPI:1780232157
Name:VEGO, STEPHANIE NATALIE (MED, BCBA)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:NATALIE
Last Name:VEGO
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:MS
Other - First Name:STEPHANIE
Other - Middle Name:NATALIE
Other - Last Name:GRILLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:612 S MYRTLE AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-3406
Mailing Address - Country:US
Mailing Address - Phone:626-775-7888
Mailing Address - Fax:
Practice Address - Street 1:612 S MYRTLE AVE STE 100
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-3406
Practice Address - Country:US
Practice Address - Phone:626-775-7888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-29
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
1-18-33114103K00000X
11833114106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1780232157Medicaid