Healthcare Provider Details

I. General information

NPI: 1942708870
Provider Name (Legal Business Name): ALISON GUADALUPE VIDAURRE LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2018
Last Update Date: 03/25/2022
Certification Date: 03/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 E FOOTHILL BLVD FL 2
PASADENA CA
91107-3406
US

IV. Provider business mailing address

PO BOX 6406
ALHAMBRA CA
91802-6406
US

V. Phone/Fax

Practice location:
  • Phone: 626-254-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number102519
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number131605
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: