Provider Demographics
NPI:1629526116
Name:VIDAL, JOANNA (SLPA)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:
Last Name:VIDAL
Suffix:
Gender:F
Credentials:SLPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8670 NW 6TH LN
Mailing Address - Street 2:APT 211
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-6830
Mailing Address - Country:US
Mailing Address - Phone:786-515-7882
Mailing Address - Fax:
Practice Address - Street 1:1550 S DIXIE HIGHWAY
Practice Address - Street 2:SUITE 203
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33146
Practice Address - Country:US
Practice Address - Phone:786-536-9714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSI 1943222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist