Provider Demographics
NPI:1215346515
Name:VIDAL, RAUL
Entity type:Individual
Prefix:MR
First Name:RAUL
Middle Name:
Last Name:VIDAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7210 N AUGUSTA DR
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-2075
Mailing Address - Country:US
Mailing Address - Phone:305-450-8892
Mailing Address - Fax:
Practice Address - Street 1:1840 W 49TH ST STE 606
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-2962
Practice Address - Country:US
Practice Address - Phone:305-827-3252
Practice Address - Fax:305-827-3298
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-12
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH5827101Y00000X, 101YM0800X
FLCAC 2321101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)