Provider Demographics
NPI:1043795164
Name:VIDAL, PRIZILA DAJIA (MPSS-LIADFM)
Entity type:Individual
Prefix:
First Name:PRIZILA
Middle Name:DAJIA
Last Name:VIDAL
Suffix:
Gender:F
Credentials:MPSS-LIADFM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 LAUREL ST PMB 531
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101
Mailing Address - Country:US
Mailing Address - Phone:619-755-4737
Mailing Address - Fax:
Practice Address - Street 1:415 LAUREL ST PMB 531
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101
Practice Address - Country:US
Practice Address - Phone:619-755-4737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-25
Last Update Date:2024-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24-QMHS-I-0008101YM0800X
172V00000X, 171W00000X
CA175T00000X
CAMPSS-LIADFM175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No172V00000XOther Service ProvidersCommunity Health Worker
No175T00000XOther Service ProvidersPeer Specialist