Provider Demographics
NPI:1467716878
Name:VIDAL, BRENDA (MS)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:
Last Name:VIDAL
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5783 N.W VENITH DRIVE
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-3529
Mailing Address - Country:US
Mailing Address - Phone:754-368-3554
Mailing Address - Fax:
Practice Address - Street 1:817 N DIXIE HWY
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33060-5621
Practice Address - Country:US
Practice Address - Phone:954-785-8285
Practice Address - Fax:954-928-0040
Is Sole Proprietor?:No
Enumeration Date:2012-06-29
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
N/AOtherN/A