Provider Demographics
NPI:1992177943
Name:VEGA, ISAELISSE M (MSW)
Entity Type:Individual
Prefix:
First Name:ISAELISSE
Middle Name:M
Last Name:VEGA
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:STARLIGHT 3049 NOVAS
Mailing Address - Street 2:
Mailing Address - City:PONCE
Mailing Address - State:PUERTO RICO
Mailing Address - Zip Code:00717
Mailing Address - Country:UM
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3049 CALLE NOVAS
Practice Address - Street 2:STARLIGHT
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00717-1476
Practice Address - Country:US
Practice Address - Phone:787-473-4451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-28
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR127871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR4683690Medicaid