Provider Demographics
NPI:1659689990
Name:FIORENTINO, VIDA ANN-NICHOLAS (PHD, LPC, SCL)
Entity Type:Individual
Prefix:DR
First Name:VIDA
Middle Name:ANN-NICHOLAS
Last Name:FIORENTINO
Suffix:
Gender:F
Credentials:PHD, LPC, SCL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12908 DIXIE
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48239-2676
Mailing Address - Country:US
Mailing Address - Phone:313-534-4380
Mailing Address - Fax:313-532-7229
Practice Address - Street 1:12908 DIXIE
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48239-2676
Practice Address - Country:US
Practice Address - Phone:313-706-2745
Practice Address - Fax:313-532-7229
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-21
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401007447101YP2500X
MI155081101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool