Provider Demographics
NPI:1518141415
Name:DE VIDAS, MICHAEL (DSW, LCSW)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:DE VIDAS
Suffix:
Gender:M
Credentials:DSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GUSTAVE L. LEVY PLACE
Mailing Address - Street 2:BOX 1059-MOUNT SINAI MEDICAL CENTER
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-6574
Mailing Address - Country:US
Mailing Address - Phone:212-241-9053
Mailing Address - Fax:212-987-1134
Practice Address - Street 1:1 GUSTAVE L. LEVY PLACE
Practice Address - Street 2:BOX 1059-MOUNT SINAI MEDICAL CENTER
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6574
Practice Address - Country:US
Practice Address - Phone:212-241-9053
Practice Address - Fax:212-987-1134
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034600-1R104100000X
NJ44SC05214500104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker