Provider Demographics
NPI:1295852846
Name:VERGARA, TACIE LEE (PSYD)
Entity type:Individual
Prefix:DR
First Name:TACIE
Middle Name:LEE
Last Name:VERGARA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 W HAINES ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-3319
Mailing Address - Country:US
Mailing Address - Phone:215-680-2365
Mailing Address - Fax:215-842-2955
Practice Address - Street 1:8200 FLOURTOWN AVE FRNT 1A
Practice Address - Street 2:
Practice Address - City:WYNDMOOR
Practice Address - State:PA
Practice Address - Zip Code:19038-7969
Practice Address - Country:US
Practice Address - Phone:215-948-3858
Practice Address - Fax:215-842-2955
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2025-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS015770103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA645588Medicare ID - Type UnspecifiedMEDICARE