Provider Demographics
NPI:1447580436
Name:VIDAL, MONIQUE DESIREE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MONIQUE
Middle Name:DESIREE
Last Name:VIDAL
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 1:3448 DOVER AVE
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-5776
Mailing Address - Country:US
Mailing Address - Phone:605-484-5258
Mailing Address - Fax:
Practice Address - Street 1:2001 DEWAR DR STE 270
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-5785
Practice Address - Country:US
Practice Address - Phone:605-484-5258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-13
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPCSW-4591041C0700X
WY8181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical