Healthcare Provider Details

I. General information

NPI: 1295375350
Provider Name (Legal Business Name): GENESIS J DE LA VERA VARGAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2020
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 LACKAWANNA AVE STE 321
SCRANTON PA
18503-1953
US

IV. Provider business mailing address

8001 SW 36TH ST
DAVIE FL
33328-1915
US

V. Phone/Fax

Practice location:
  • Phone: 866-872-7601
  • Fax:
Mailing address:
  • Phone: 954-577-7790
  • Fax: 954-577-7780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBH007037
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: