Provider Demographics
NPI:1770679425
Name:VEDROS, DANI
Entity Type:Individual
Prefix:
First Name:DANI
Middle Name:
Last Name:VEDROS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 WESTOVER AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1623
Mailing Address - Country:US
Mailing Address - Phone:757-288-9741
Mailing Address - Fax:757-622-3944
Practice Address - Street 1:1611 COLLEY AVE D
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23517-1677
Practice Address - Country:US
Practice Address - Phone:757-472-5245
Practice Address - Fax:757-622-3944
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040028841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009999124Medicaid