Provider Demographics
NPI:1801569876
Name:VIDRO, MOISE (RBT)
Entity type:Individual
Prefix:
First Name:MOISE
Middle Name:
Last Name:VIDRO
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2707 FLORENCE DR
Mailing Address - Street 2:
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42240-1637
Mailing Address - Country:US
Mailing Address - Phone:803-201-0792
Mailing Address - Fax:
Practice Address - Street 1:2707 FLORENCE DR
Practice Address - Street 2:
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-1637
Practice Address - Country:US
Practice Address - Phone:803-201-0792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-27
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRBT-21-175735106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNRBT-21-175735OtherBEHAVIOR TECHNICIAN