Provider Demographics
NPI:1720500663
Name:VEGA, MAYRA C
Entity Type:Individual
Prefix:
First Name:MAYRA
Middle Name:C
Last Name:VEGA
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 1:4750 59TH ST APT 1E
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-5517
Mailing Address - Country:US
Mailing Address - Phone:917-586-7737
Mailing Address - Fax:
Practice Address - Street 1:14015B SANFORD AVE FL 2
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-2557
Practice Address - Country:US
Practice Address - Phone:185-528-3214
Practice Address - Fax:855-283-2146
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-12
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY102881-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP06862OtherTEMPORARY LMSW PERMIT