Provider Demographics
NPI:1285867283
Name:VIDACOVICH, ANNE A (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ANNE
Middle Name:A
Last Name:VIDACOVICH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:446 W NORTHGATE DR
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75062-3616
Mailing Address - Country:US
Mailing Address - Phone:214-597-3575
Mailing Address - Fax:
Practice Address - Street 1:446 W NORTHGATE DR
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75062-3616
Practice Address - Country:US
Practice Address - Phone:214-597-3575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-25
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX140701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical