MEDICARE: WILDALIZ VARGAS B.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC1900X	Counseling Psychologist

General Provider Information

NPI Number	:	1578019816
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILDALIZ VARGAS B.S.

Provider Business Mailing Address
First Line	:	260 S. ORANGE BLOSSOM TRAIL, SUITE 261
Second Line	:	UNIT240
City	:	ORLANDO
State	:	FL
Zip	:	32805-3234
Country	:	US
Telephone Number	:	407-270-6685
Fax Number	:

Provider Business Practice Location Address
First Line	:	260 S. ORANGE BLOSSOM TRAIL, SUITE 261
Second Line	:	UNIT240
City	:	ORLANDO
State	:	FL
Zip	:	32805-3234
Country	:	US
Telephone Number	:	407-270-6685
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/28/2016
Last Update Date	:	08/28/2016

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