Provider Demographics
NPI:1043886641
Name:VIELMA, JUDITH ARACELY
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:ARACELY
Last Name:VIELMA
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 1:1224 ARTHUR ST
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-3826
Mailing Address - Country:US
Mailing Address - Phone:208-809-0773
Mailing Address - Fax:
Practice Address - Street 1:1224 ARTHUR ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-3826
Practice Address - Country:US
Practice Address - Phone:208-809-0773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-03
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDBB234011I106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty