Provider Demographics
NPI:1295852846
Name:VERGARA, TACIE LEE (PSYD)
Entity type:Individual
Prefix:DR
First Name:TACIE
Middle Name:LEE
Last Name:VERGARA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 W HAINES ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-3319
Mailing Address - Country:US
Mailing Address - Phone:221-584-2295
Mailing Address - Fax:215-842-3209
Practice Address - Street 1:8431 GERMANTOWN AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19118-3301
Practice Address - Country:US
Practice Address - Phone:215-247-9555
Practice Address - Fax:215-842-3209
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS015770103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA645588Medicare ID - Type UnspecifiedMEDICARE