Provider Demographics
NPI:1073041026
Name:VIDAURRI, DESIRAE NICOLLE (PHD)
Entity Type:Individual
Prefix:DR
First Name:DESIRAE
Middle Name:NICOLLE
Last Name:VIDAURRI
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MS
Other - First Name:DESRIAE
Other - Middle Name:NICOLLE
Other - Last Name:BOLDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:144 ELK PL APT 1507
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70112-2636
Mailing Address - Country:US
Mailing Address - Phone:512-538-8051
Mailing Address - Fax:
Practice Address - Street 1:2400 CANAL ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-6535
Practice Address - Country:US
Practice Address - Phone:504-507-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-02
Last Update Date:2017-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810005697103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical