Healthcare Provider Details

I. General information

NPI: 1902073869
Provider Name (Legal Business Name): MARYORIE VEGA MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2008
Last Update Date: 07/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

184 CALLE GUADALUPE
PONCE PR
00730-3561
US

IV. Provider business mailing address

11 AVE LIBORIO LOPEZ
SABANA GRANDE PR
00637-2036
US

V. Phone/Fax

Practice location:
  • Phone: 787-753-9515
  • Fax: 787-753-8327
Mailing address:
  • Phone: 787-215-3653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number8903
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number5616
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: