Provider Demographics
NPI:1528289980
Name:VIDRINE, DAVELYN V (PHD)
Entity type:Individual
Prefix:DR
First Name:DAVELYN
Middle Name:V
Last Name:VIDRINE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4431
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37405-0431
Mailing Address - Country:US
Mailing Address - Phone:423-266-0776
Mailing Address - Fax:
Practice Address - Street 1:113 STRINGER ST
Practice Address - Street 2:SUITE A
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37405-3254
Practice Address - Country:US
Practice Address - Phone:423-266-0776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNIP00001761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNIP0000276OtherLICENSE TO PRACTICE