Healthcare Provider Details

I. General information

NPI: 1386414258
Provider Name (Legal Business Name): MIRELYS VACCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2024
Last Update Date: 01/03/2024
Certification Date: 01/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 CHURCH ST
LOWELL MA
01852-6113
US

IV. Provider business mailing address

13 THERRIAULT AVE
SALEM NH
03079-2609
US

V. Phone/Fax

Practice location:
  • Phone: 978-674-6744
  • Fax: 978-441-9826
Mailing address:
  • Phone: 978-943-8859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number230138
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: