Provider Demographics
NPI:1518785013
Name:VEGA, GUSTAVO (CRC, CATC-IV)
Entity type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
Last Name:VEGA
Suffix:
Gender:M
Credentials:CRC, CATC-IV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 CAMINO DEL RIO S STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3567
Mailing Address - Country:US
Mailing Address - Phone:619-701-3211
Mailing Address - Fax:
Practice Address - Street 1:1011 CAMINO DEL RIO S STE 300
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3567
Practice Address - Country:US
Practice Address - Phone:619-701-3211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional