Healthcare Provider Details

I. General information

NPI: 1255251526
Provider Name (Legal Business Name): IDALIS MONIQUE PULIDO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: IDALIS MONIQUE PULIDO-BLACK

II. Dates (important events)

Enumeration Date: 07/17/2026
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3048 E BASELINE RD STE 123
MESA AZ
85204-7288
US

IV. Provider business mailing address

9526 E RAINBOW AVE
MESA AZ
85212-1185
US

V. Phone/Fax

Practice location:
  • Phone: 480-359-5001
  • Fax:
Mailing address:
  • Phone: 818-802-0898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1457230518
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: