Provider Demographics
NPI:1205955291
Name:VIDES, EVELYN E
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:E
Last Name:VIDES
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 1:3485 CHANDLER CIR
Mailing Address - Street 2:
Mailing Address - City:BAY POINT
Mailing Address - State:CA
Mailing Address - Zip Code:94565-6917
Mailing Address - Country:US
Mailing Address - Phone:925-787-9303
Mailing Address - Fax:
Practice Address - Street 1:1350 ARNOLD DR STE 102
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:CA
Practice Address - Zip Code:94553-4190
Practice Address - Country:US
Practice Address - Phone:925-313-9562
Practice Address - Fax:925-228-2932
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X, 1041C0700X, 390200000X, 101YM0800X
CA899691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program