Provider Demographics
NPI:1942699855
Name:VIDAL, AILSA (PTA)
Entity type:Individual
Prefix:
First Name:AILSA
Middle Name:
Last Name:VIDAL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4312 SW 68TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-4750
Mailing Address - Country:US
Mailing Address - Phone:305-546-5333
Mailing Address - Fax:
Practice Address - Street 1:4262 SW 68TH CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-4749
Practice Address - Country:US
Practice Address - Phone:305-546-5333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-15
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPTA25059OtherLICENSE NUMBER