Healthcare Provider Details

I. General information

NPI: 1528516341
Provider Name (Legal Business Name): DANIELLE MARIE VIDART LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DANIELLE MARIE BOWEN

II. Dates (important events)

Enumeration Date: 09/21/2016
Last Update Date: 04/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19330 JESSE LN STE 280
RIVERSIDE CA
92508-5091
US

IV. Provider business mailing address

PO BOX 1695
LEMON GROVE CA
91946-1695
US

V. Phone/Fax

Practice location:
  • Phone: 951-387-4040
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number95249
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: