MEDICARE: GISELA M VEGA

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
2	390200000X	Student in an Organized Health Care Education/Training Program
3	103T00000X	Psychologist	32944	CA

General Provider Information

NPI Number	:	1104312586
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GISELA M VEGA

Provider Business Mailing Address
First Line	:	1124 E PACIFIC COAST HWY # 1010
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90806-5102
Country	:	US
Telephone Number	:	610-732-7672
Fax Number	:

Provider Business Practice Location Address
First Line	:	1124 E PACIFIC COAST HWY # 1010
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90806-5102
Country	:	US
Telephone Number	:	610-732-7672
Fax Number	:

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

Provider Enumeration Date	:	07/09/2018
Last Update Date	:	11/09/2021

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Directions to “ GISELA M VEGA ” Practice Location

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