Provider Demographics
NPI:1780938407
Name:VEGA, ANDY
Entity type:Individual
Prefix:
First Name:ANDY
Middle Name:
Last Name:VEGA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ANDRES
Other - Middle Name:
Other - Last Name:VEGA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1724 GARDEN SAGE DR
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-4617
Mailing Address - Country:US
Mailing Address - Phone:321-544-3328
Mailing Address - Fax:
Practice Address - Street 1:1724 GARDEN SAGE DR
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-4617
Practice Address - Country:US
Practice Address - Phone:321-544-3328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-02
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-01-0532103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1-01-0532OtherBCBA