Provider Demographics
NPI:1902872872
Name:VIDOR, GARY LEE (PHD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:LEE
Last Name:VIDOR
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 FOOTHILL BLVD
Mailing Address - Street 2:SUITE 10
Mailing Address - City:LA CANADA
Mailing Address - State:CA
Mailing Address - Zip Code:91011-2146
Mailing Address - Country:US
Mailing Address - Phone:818-790-0110
Mailing Address - Fax:
Practice Address - Street 1:1313 FOOTHILL BLVD
Practice Address - Street 2:SUITE 10
Practice Address - City:LA CANADA
Practice Address - State:CA
Practice Address - Zip Code:91011-2146
Practice Address - Country:US
Practice Address - Phone:818-790-0110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-28
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 5219103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist