MEDICARE: YADYRA LEE VEGA LOPEZ

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	1684	PR

General Provider Information

NPI Number	:	1356152441
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	YADYRA LEE VEGA LOPEZ

Provider Business Mailing Address
First Line	:	8745 JAMESTOWN DR
Second Line	:
City	:	WINTER HAVEN
State	:	FL
Zip	:	33884-4840
Country	:	US
Telephone Number	:	787-295-5716
Fax Number	:

Provider Business Practice Location Address
First Line	:	5726 OLD CHENEY HWY
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32807-3525
Country	:	US
Telephone Number	:	407-900-5278
Fax Number	:	407-641-2980

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

Provider Enumeration Date	:	01/16/2025
Last Update Date	:	01/16/2025

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