Healthcare Provider Details

I. General information

NPI: 1659680288
Provider Name (Legal Business Name): ANASTASIA E. VEGA SAC-IT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANASTASIA E. NEDD SAC-IT

II. Dates (important events)

Enumeration Date: 09/30/2010
Last Update Date: 09/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6416 S HOWELL AVE
OAK CREEK WI
53154-1104
US

IV. Provider business mailing address

285 N JANACEK RD
BROOKFIELD WI
53045-6102
US

V. Phone/Fax

Practice location:
  • Phone: 414-762-5429
  • Fax: 414-762-9727
Mailing address:
  • Phone: 262-641-9050
  • Fax: 262-641-9126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number15636-130
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: