Provider Demographics
NPI:1174104335
Name:VERGARA, ALEXANDRA (MA, BCBA, LBA)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:VERGARA
Suffix:
Gender:F
Credentials:MA, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 117TH ST
Mailing Address - Street 2:
Mailing Address - City:COLLEGE POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11356-1545
Mailing Address - Country:US
Mailing Address - Phone:646-457-1011
Mailing Address - Fax:
Practice Address - Street 1:1 BARSTOW RD
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-3540
Practice Address - Country:US
Practice Address - Phone:516-441-5255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002086-21103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst