Basic Information
| Provider Information | |||||||||
| NPI: | 1972631539 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VEGA | ||||||||
| FirstName: | EVELYN | ||||||||
| MiddleName: | |||||||||
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| Credential: | LMFT | ||||||||
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| OtherLastName: | VEGA | ||||||||
| OtherFirstName: | EVELYN | ||||||||
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| OtherCredential: | LMFT | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 530 S LAKE AVE # 954 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911013515 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1172 N MACLAY AVE | ||||||||
| Address2: | |||||||||
| City: | SAN FERNANDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913401328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188981388 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2007 | ||||||||
| LastUpdateDate: | 12/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFC43733 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.