Provider Demographics
NPI:1366329716
Name:VEGA-WAGNER, MARILYN ALEJANDRA
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:ALEJANDRA
Last Name:VEGA-WAGNER
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 1:989 LYNN CT
Mailing Address - Street 2:
Mailing Address - City:RIPON
Mailing Address - State:CA
Mailing Address - Zip Code:95366-3364
Mailing Address - Country:US
Mailing Address - Phone:916-690-3086
Mailing Address - Fax:
Practice Address - Street 1:1998 YOSEMITE AVE
Practice Address - Street 2:
Practice Address - City:ESCALON
Practice Address - State:CA
Practice Address - Zip Code:95320-1845
Practice Address - Country:US
Practice Address - Phone:209-838-7031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-18
Last Update Date:2025-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool