Provider Demographics
NPI:1104611326
Name:VIDAL, SARA ELIZABETH (LMSW)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:ELIZABETH
Last Name:VIDAL
Suffix:
Gender:
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 HECTOR ST
Mailing Address - Street 2:
Mailing Address - City:TRUMANSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14886-9554
Mailing Address - Country:US
Mailing Address - Phone:607-882-4121
Mailing Address - Fax:
Practice Address - Street 1:127 W STATE ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-5474
Practice Address - Country:US
Practice Address - Phone:697-273-7494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-09
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY126399104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker