Provider Demographics
NPI:1265035158
Name:VASCONEZ, MAGDALENE KIDD
Entity Type:Individual
Prefix:
First Name:MAGDALENE
Middle Name:KIDD
Last Name:VASCONEZ
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 1:107 WESTOVER DR
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31407-3903
Mailing Address - Country:US
Mailing Address - Phone:912-755-0906
Mailing Address - Fax:
Practice Address - Street 1:107 WESTOVER DR
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31407-3903
Practice Address - Country:US
Practice Address - Phone:912-755-0906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-21
Last Update Date:2020-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0072191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical