Provider Demographics
NPI:1821352469
Name:VIDAL, LAURA LILLIA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:LILLIA
Last Name:VIDAL
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 1:6615 VALLEY HI DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-7076
Mailing Address - Country:US
Mailing Address - Phone:916-450-2650
Mailing Address - Fax:
Practice Address - Street 1:6615 VALLEY HI DR
Practice Address - Street 2:SUITE A
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-7076
Practice Address - Country:US
Practice Address - Phone:916-450-2650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-28
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW33713104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker