Healthcare Provider Details

I. General information

NPI: 1609506070
Provider Name (Legal Business Name): BREANNA VARGAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2022
Last Update Date: 06/23/2022
Certification Date: 06/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1811 GRAND CANAL BLVD STE 2
STOCKTON CA
95207-8107
US

IV. Provider business mailing address

4770 WEST LN UNIT 11101
STOCKTON CA
95210-3573
US

V. Phone/Fax

Practice location:
  • Phone: 209-452-8996
  • Fax:
Mailing address:
  • Phone: 209-598-7671
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: