Provider Demographics
NPI:1427717255
Name:DIAZ-VIDAILLET, ANGELA
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:DIAZ-VIDAILLET
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 NW 107TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI SHORES
Mailing Address - State:FL
Mailing Address - Zip Code:33168-4306
Mailing Address - Country:US
Mailing Address - Phone:305-542-4128
Mailing Address - Fax:
Practice Address - Street 1:65 NW 107TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI SHORES
Practice Address - State:FL
Practice Address - Zip Code:33168-4306
Practice Address - Country:US
Practice Address - Phone:305-542-4128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-09
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
FLMH2353101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional