Provider Demographics
NPI:1265033047
Name:VIDAL, ROSA ISELA (LPC)
Entity Type:Individual
Prefix:
First Name:ROSA
Middle Name:ISELA
Last Name:VIDAL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 W DOVE AVE
Mailing Address - Street 2:
Mailing Address - City:PHARR
Mailing Address - State:TX
Mailing Address - Zip Code:78577-9080
Mailing Address - Country:US
Mailing Address - Phone:956-354-5153
Mailing Address - Fax:
Practice Address - Street 1:710 W DOVE AVE
Practice Address - Street 2:
Practice Address - City:PHARR
Practice Address - State:TX
Practice Address - Zip Code:78577-9080
Practice Address - Country:US
Practice Address - Phone:956-354-5153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX79595101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
15000280OtherCAQH