Provider Demographics
NPI:1972969889
Name:VERGARA, MARYBETH
Entity type:Individual
Prefix:
First Name:MARYBETH
Middle Name:
Last Name:VERGARA
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 1:4228 OBISPO AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90712-4025
Mailing Address - Country:US
Mailing Address - Phone:562-277-5080
Mailing Address - Fax:
Practice Address - Street 1:3232 E ARTESIA BLVD
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90805-2811
Practice Address - Country:US
Practice Address - Phone:562-422-9219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-07
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9472225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant