Provider Demographics
NPI:1730203282
Name:VIDALES, LETICIA T (MA, MFT)
Entity type:Individual
Prefix:MS
First Name:LETICIA
Middle Name:T
Last Name:VIDALES
Suffix:
Gender:F
Credentials:MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 TELEGRAPH RD STE 175
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-4251
Mailing Address - Country:US
Mailing Address - Phone:805-658-2105
Mailing Address - Fax:805-617-1831
Practice Address - Street 1:5500 TELEGRAPH RD STE 175
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-4251
Practice Address - Country:US
Practice Address - Phone:805-658-2105
Practice Address - Fax:805-617-1831
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47119106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist