Provider Demographics
NPI:1649861246
Name:VIDRINE, KALI
Entity type:Individual
Prefix:
First Name:KALI
Middle Name:
Last Name:VIDRINE
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 1:10465 ROYAL TRICIA DR
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77303-2769
Mailing Address - Country:US
Mailing Address - Phone:281-787-2098
Mailing Address - Fax:
Practice Address - Street 1:611 ROCKMEAD DR STE 100
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77339-2294
Practice Address - Country:US
Practice Address - Phone:281-713-8980
Practice Address - Fax:281-713-8938
Is Sole Proprietor?:No
Enumeration Date:2021-01-27
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-19-90411106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician