Provider Demographics
NPI:1851071153
Name:VEGA, BIANCA CELEST I
Entity Type:Individual
Prefix:
First Name:BIANCA
Middle Name:CELEST
Last Name:VEGA
Suffix:I
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 1:2408 MICHELLE RD SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87105-4920
Mailing Address - Country:US
Mailing Address - Phone:505-217-4603
Mailing Address - Fax:
Practice Address - Street 1:2408 MICHELLE RD SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87105-4920
Practice Address - Country:US
Practice Address - Phone:505-357-8498
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-20
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM516814152106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician