Provider Demographics
NPI:1356152441
Name:VEGA LOPEZ, YADYRA LEE
Entity type:Individual
Prefix:
First Name:YADYRA
Middle Name:LEE
Last Name:VEGA LOPEZ
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 1:8745 JAMESTOWN DR
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33884-4840
Mailing Address - Country:US
Mailing Address - Phone:787-295-5716
Mailing Address - Fax:
Practice Address - Street 1:5726 OLD CHENEY HWY
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32807-3525
Practice Address - Country:US
Practice Address - Phone:407-900-5278
Practice Address - Fax:407-641-2980
Is Sole Proprietor?:No
Enumeration Date:2025-01-16
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1684101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health