Provider Demographics
NPI:1912661661
Name:VEGA-MOLINA, STEPHANIE MARIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MARIE
Last Name:VEGA-MOLINA
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 1:3600 GASTON AVE STE 404
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1804
Mailing Address - Country:US
Mailing Address - Phone:214-820-5516
Mailing Address - Fax:214-820-5518
Practice Address - Street 1:3600 GASTON AVE STE 404
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1804
Practice Address - Country:US
Practice Address - Phone:214-820-5516
Practice Address - Fax:214-820-5528
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-28
Last Update Date:2022-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39275103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty