Healthcare Provider Details

I. General information

NPI: 1598006025
Provider Name (Legal Business Name): KRISTINA MARIE VACHA L.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2013
Last Update Date: 03/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 LOCUST LN
MEDIA PA
19063-1711
US

IV. Provider business mailing address

126 LOCUST LN
MEDIA PA
19063-1711
US

V. Phone/Fax

Practice location:
  • Phone: 484-274-8957
  • Fax:
Mailing address:
  • Phone: 484-274-8957
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW129861
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: