Healthcare Provider Details

I. General information

NPI: 1063248391
Provider Name (Legal Business Name): DR LUISA VEGA DNP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2024
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 TECHNOLOGY PARK STE 109
LAKE MARY FL
32746-7107
US

IV. Provider business mailing address

PO BOX 117746
ATLANTA GA
30368-7746
US

V. Phone/Fax

Practice location:
  • Phone: 407-647-2346
  • Fax:
Mailing address:
  • Phone: 407-647-2346
  • Fax: 407-647-5431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: LUISA SOLER VEGA
Title or Position: OWNER
Credential: DNP
Phone: 407-647-2346