Healthcare Provider Details

I. General information

NPI: 1114863263
Provider Name (Legal Business Name): ELIZABETH VEGA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2026
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6641 LONE TREE WAY
BRENTWOOD CA
94513-5314
US

IV. Provider business mailing address

6641 LONE TREE WAY
BRENTWOOD CA
94513-5314
US

V. Phone/Fax

Practice location:
  • Phone: 866-375-2437
  • Fax:
Mailing address:
  • Phone: 866-375-2437
  • Fax: 408-273-6905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-479211
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: