Provider Demographics
NPI:1821243064
Name:VIDAURRI, REINA PEREZ (LCSW)
Entity Type:Individual
Prefix:
First Name:REINA
Middle Name:PEREZ
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 1:529 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90013-1511
Mailing Address - Country:US
Mailing Address - Phone:213-430-6714
Mailing Address - Fax:310-895-6236
Practice Address - Street 1:529 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90013-1511
Practice Address - Country:US
Practice Address - Phone:213-430-6714
Practice Address - Fax:310-895-6236
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-01
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 140761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALCS14076Medicaid