1790121176 NPI number — MRS. STEPHANIE CATHERINE VIDAURRI LCSW

Table of content: MRS. STEPHANIE CATHERINE VIDAURRI LCSW (NPI 1790121176)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790121176 NPI number — MRS. STEPHANIE CATHERINE VIDAURRI LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VIDAURRI
Provider First Name:
STEPHANIE
Provider Middle Name:
CATHERINE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790121176
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/13/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8 ANAE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA RITA
Provider Business Mailing Address State Name:
GU
Provider Business Mailing Address Postal Code:
96915-1433
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
671-564-1789
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
498 CHALAN PALOSYO
Provider Second Line Business Practice Location Address:
GUAM VA CBOC
Provider Business Practice Location Address City Name:
AGANA HEIGHTS
Provider Business Practice Location Address State Name:
GU
Provider Business Practice Location Address Postal Code:
96910-6427
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
671-475-5800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/13/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  LCSW 3734 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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