Provider Demographics
NPI:1750639142
Name:WEATHERFORD WALSH, VIDA L (LPC,LCDC)
Entity Type:Individual
Prefix:MRS
First Name:VIDA
Middle Name:L
Last Name:WEATHERFORD WALSH
Suffix:
Gender:F
Credentials:LPC,LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 S AUSTIN AVE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-5707
Mailing Address - Country:US
Mailing Address - Phone:512-966-4271
Mailing Address - Fax:
Practice Address - Street 1:624 S AUSTIN AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-5707
Practice Address - Country:US
Practice Address - Phone:512-966-4271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11166101YA0400X
TX65085101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)