Provider Demographics
NPI:1649919077
Name:VIDI, LINDA (LACY)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:VIDI
Suffix:
Gender:F
Credentials:LACY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1224
Mailing Address - Street 2:
Mailing Address - City:MANAHAWKIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08050-8224
Mailing Address - Country:US
Mailing Address - Phone:609-339-8093
Mailing Address - Fax:
Practice Address - Street 1:1296 E BAY AVE
Practice Address - Street 2:
Practice Address - City:MANAHAWKIN
Practice Address - State:NJ
Practice Address - Zip Code:08050-3942
Practice Address - Country:US
Practice Address - Phone:609-339-8093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00506300101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health