Provider Demographics
NPI:1528848090
Name:VIDAL ROSALES, SYNTHIA MARGARITA
Entity type:Individual
Prefix:
First Name:SYNTHIA
Middle Name:MARGARITA
Last Name:VIDAL ROSALES
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 1:8508 N 10TH ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33604-1710
Mailing Address - Country:US
Mailing Address - Phone:813-601-5357
Mailing Address - Fax:
Practice Address - Street 1:8508 N 10TH ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33604-1710
Practice Address - Country:US
Practice Address - Phone:813-601-5357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-03
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-292310106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty