Provider Demographics
NPI:1871618728
Name:VARGAS, MIGUELINA J (PHD)
Entity type:Individual
Prefix:
First Name:MIGUELINA
Middle Name:J
Last Name:VARGAS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4175 SANDBERG DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80911-3441
Mailing Address - Country:US
Mailing Address - Phone:719-205-4309
Mailing Address - Fax:719-205-4309
Practice Address - Street 1:1304 N ACADEMY BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-3325
Practice Address - Country:US
Practice Address - Phone:719-205-4309
Practice Address - Fax:719-465-3576
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2647103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO11421835Medicaid
CO811196OtherPTAN