Provider Demographics
NPI:1255705208
Name:VEGA, KENNY
Entity type:Individual
Prefix:
First Name:KENNY
Middle Name:
Last Name:VEGA
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 1:14921 SW 283RD ST APT 307
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33033-1584
Mailing Address - Country:US
Mailing Address - Phone:609-350-0686
Mailing Address - Fax:
Practice Address - Street 1:14921 SW 283RD ST APT 307
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33033-1584
Practice Address - Country:US
Practice Address - Phone:609-350-0686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-13
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH23844101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty