Provider Demographics
NPI:1902583347
Name:VACA, MYRA E
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:E
Last Name:VACA
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 1:1920 STATE HIGHWAY 65 STE 290
Mailing Address - Street 2:
Mailing Address - City:WHEATLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95692-9006
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1920 STATE HIGHWAY 65 STE 290
Practice Address - Street 2:
Practice Address - City:WHEATLAND
Practice Address - State:CA
Practice Address - Zip Code:95692-9006
Practice Address - Country:US
Practice Address - Phone:916-729-3098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-28
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician