1225222557 NPI number — DESIREE EILEEN MIRANDA VEGA MFT

Table of content: DESIREE EILEEN MIRANDA VEGA MFT (NPI 1225222557)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225222557 NPI number — DESIREE EILEEN MIRANDA VEGA MFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VEGA
Provider First Name:
DESIREE
Provider Middle Name:
EILEEN MIRANDA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MFT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225222557
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/06/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1662 FREMONT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIMI VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93065-4524
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-427-3891
Provider Business Mailing Address Fax Number:
818-855-7428

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11145 TAMPA AVE STE 15A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTHRIDGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-427-3891
Provider Business Practice Location Address Fax Number:
818-855-7428
Provider Enumeration Date:
08/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  IMF50330 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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