Provider Demographics
NPI:1386414258
Name:VACCA, MIRELYS
Entity type:Individual
Prefix:
First Name:MIRELYS
Middle Name:
Last Name:VACCA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 THERRIAULT AVE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:NH
Mailing Address - Zip Code:03079-2609
Mailing Address - Country:US
Mailing Address - Phone:978-943-8859
Mailing Address - Fax:
Practice Address - Street 1:40 CHURCH ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-6113
Practice Address - Country:US
Practice Address - Phone:978-674-6744
Practice Address - Fax:978-441-9826
Is Sole Proprietor?:No
Enumeration Date:2024-01-03
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2301381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical