MEDICARE: KAREN LEE VERGAMINI M.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	L.P.C. 1392	AZ

General Provider Information

NPI Number	:	1063658979
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAREN LEE VERGAMINI M.C.

Provider Business Mailing Address
First Line	:	4617 W WAHALLA LN
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85308-7335
Country	:	US
Telephone Number	:	623-492-9450
Fax Number	:	623-580-8511

Provider Business Practice Location Address
First Line	:	3520 W. DANBURY
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85308
Country	:	US
Telephone Number	:	623-492-9450
Fax Number	:	623-580-8511

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/23/2008
Last Update Date	:	12/23/2008

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