1255480596 NPI number — MARIELA VARGAS PSY.D

Table of content: MARIELA VARGAS PSY.D (NPI 1255480596)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255480596 NPI number — MARIELA VARGAS PSY.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VARGAS
Provider First Name:
MARIELA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PSY.D
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:
1255480596
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/25/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
110 CEDAR STREET
Provider Second Line Business Mailing Address:
SUITE 10
Provider Business Mailing Address City Name:
WELLESLEY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02481-5323
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-902-8393
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 CEDAR STREET
Provider Second Line Business Practice Location Address:
SUITE 10
Provider Business Practice Location Address City Name:
WELLESLEY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02481-5323
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-902-8393
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/09/2007

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: 103G00000X , with the licence number:  7783 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103K00000X , with the licence number: 1123 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: W06397 . This is a "BLUE CROSS PROVIDER #" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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