Provider Demographics
NPI:1700492816
Name:VIDAL, MONICA (MS)
Entity Type:Individual
Prefix:MS
First Name:MONICA
Middle Name:
Last Name:VIDAL
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43712 TOWNE ST
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-2458
Mailing Address - Country:US
Mailing Address - Phone:760-673-8342
Mailing Address - Fax:
Practice Address - Street 1:49211 GRAPEFRUIT BLVD STE 5
Practice Address - Street 2:
Practice Address - City:COACHELLA
Practice Address - State:CA
Practice Address - Zip Code:92236-1480
Practice Address - Country:US
Practice Address - Phone:760-541-8520
Practice Address - Fax:760-262-3795
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT104623106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist