Provider Demographics
NPI:1750707105
Name:VEGA GRANADOS, LAURA PATRICIA (MFT)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:PATRICIA
Last Name:VEGA GRANADOS
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:PATRICIA
Other - Last Name:VEGA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1000 CORPORATE CENTER DR STE 650
Mailing Address - Street 2:
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-7639
Mailing Address - Country:US
Mailing Address - Phone:323-526-4016
Mailing Address - Fax:
Practice Address - Street 1:149 S MEDNIK AVE # 201
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-1606
Practice Address - Country:US
Practice Address - Phone:323-981-9714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-10
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 78916106H00000X
CA105386106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist