Healthcare Provider Details

I. General information

NPI: 1043569221
Provider Name (Legal Business Name): MARYCRUZ VARGAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2012
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 12TH ST
MODESTO CA
95354-0834
US

IV. Provider business mailing address

1601 I STREET, STE. 200 SECOND FLOOR
MODESTO CA
95354-1110
US

V. Phone/Fax

Practice location:
  • Phone: 209-525-6043
  • Fax:
Mailing address:
  • Phone: 209-525-6225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: