Provider Demographics
NPI:1972189082
Name:VARGAS, YAIXSA
Entity Type:Individual
Prefix:
First Name:YAIXSA
Middle Name:
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 1:48 HULL ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06706-1824
Mailing Address - Country:US
Mailing Address - Phone:203-565-1012
Mailing Address - Fax:
Practice Address - Street 1:174 ALLYN ST
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040-2550
Practice Address - Country:US
Practice Address - Phone:203-565-1012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-19
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA247200000X106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst