Provider Demographics
NPI:1093156671
Name:VIDANA, MICHELLE (LPCC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:VIDANA
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:MRS
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:LU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPCC
Mailing Address - Street 1:9666 BUSINESSPARK AVE STE 207
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131-1646
Mailing Address - Country:US
Mailing Address - Phone:858-367-0525
Mailing Address - Fax:
Practice Address - Street 1:1202 MORENA BLVD STE 300
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-3844
Practice Address - Country:US
Practice Address - Phone:619-276-8113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-11
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YM0800X
CA5686101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional