Provider Demographics
NPI:1598136749
Name:VEGA, GEORGINA
Entity type:Individual
Prefix:
First Name:GEORGINA
Middle Name:
Last Name:VEGA
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 1:878 CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:HOLTVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92250-1108
Mailing Address - Country:US
Mailing Address - Phone:760-556-8520
Mailing Address - Fax:
Practice Address - Street 1:1612 1ST ST
Practice Address - Street 2:
Practice Address - City:COACHELLA
Practice Address - State:CA
Practice Address - Zip Code:92236-1407
Practice Address - Country:US
Practice Address - Phone:760-398-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-14
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 225C00000X
CAAMFT135987106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor