Provider Demographics
NPI:1730361262
Name:VIDAL, SANDRA (MS)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:VIDAL
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12001 DR MARTIN LUTHER KING JR ST N
Mailing Address - Street 2:APT 2611
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33716-1618
Mailing Address - Country:US
Mailing Address - Phone:941-284-1821
Mailing Address - Fax:
Practice Address - Street 1:4425 PARK BLVD
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33781-3540
Practice Address - Country:US
Practice Address - Phone:727-235-3429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH6318101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health