Provider Demographics
NPI:1346611548
Name:VIDAL, SANDRA
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:VIDAL
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 1:9242 NORTHLAKE PKWY
Mailing Address - Street 2:APT 107
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32827-5721
Mailing Address - Country:US
Mailing Address - Phone:407-721-3708
Mailing Address - Fax:
Practice Address - Street 1:9242 NORTHLAKE PKWY
Practice Address - Street 2:APT 107
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-5721
Practice Address - Country:US
Practice Address - Phone:407-721-3708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-13
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA7040235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL888545100Medicaid