Provider Demographics
NPI:1902928666
Name:VEGA, ENRIQUE (LCSW)
Entity Type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:
Last Name:VEGA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10773 111TH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11419-2417
Mailing Address - Country:US
Mailing Address - Phone:718-835-2785
Mailing Address - Fax:
Practice Address - Street 1:2324 FOREST AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10303
Practice Address - Country:US
Practice Address - Phone:718-447-0200
Practice Address - Fax:718-981-1431
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY072521-1101Y00000X
1041C0700X
NY0725211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor