Provider Demographics
NPI:1124362389
Name:VIDAL, MICHELLE (LICSW)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:VIDAL
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 GOVERNORS AVE
Mailing Address - Street 2:LAWRENCE MEMORIAL HOSPITAL
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-1643
Mailing Address - Country:US
Mailing Address - Phone:781-306-6008
Mailing Address - Fax:
Practice Address - Street 1:170 GOVERNORS AVE
Practice Address - Street 2:LAWRENCE MEMORIAL HOSPITAL
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-1643
Practice Address - Country:US
Practice Address - Phone:781-306-6008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-12
Last Update Date:2012-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1149431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical