Provider Demographics
NPI:1063528909
Name:GUEVARA, VIDAL JR (MA, LPC-S, LSSP)
Entity type:Individual
Prefix:
First Name:VIDAL
Middle Name:
Last Name:GUEVARA
Suffix:JR
Gender:M
Credentials:MA, LPC-S, LSSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 COMMERCE ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901-5510
Mailing Address - Country:US
Mailing Address - Phone:361-570-1444
Mailing Address - Fax:
Practice Address - Street 1:2002 COMMERCE ST
Practice Address - Street 2:SUITE C
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901-5510
Practice Address - Country:US
Practice Address - Phone:361-570-1444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14262101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional