Provider Demographics
NPI:1790121176
Name:VIDAURRI, STEPHANIE CATHERINE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:CATHERINE
Last Name:VIDAURRI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 ANAE LN
Mailing Address - Street 2:
Mailing Address - City:SANTA RITA
Mailing Address - State:GU
Mailing Address - Zip Code:96915-1433
Mailing Address - Country:US
Mailing Address - Phone:671-564-1789
Mailing Address - Fax:
Practice Address - Street 1:498 CHALAN PALOSYO
Practice Address - Street 2:GUAM VA CBOC
Practice Address - City:AGANA HEIGHTS
Practice Address - State:GU
Practice Address - Zip Code:96910-6427
Practice Address - Country:US
Practice Address - Phone:671-475-5800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-13
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HILCSW 37341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical