Healthcare Provider Details

I. General information

NPI: 1174727440
Provider Name (Legal Business Name): JOSE VARGAS LCSW, CASAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 10/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 MILL DR
MASTIC BEACH NY
11951-1803
US

IV. Provider business mailing address

14 MILL DR
MASTIC BEACH NY
11951-1803
US

V. Phone/Fax

Practice location:
  • Phone: 631-745-8205
  • Fax:
Mailing address:
  • Phone: 631-745-8205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number16811
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number078403-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: