Healthcare Provider Details

I. General information

NPI: 1043795164
Provider Name (Legal Business Name): PRIZILA DAJIA VIDAL MPSS-LIADFM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2018
Last Update Date: 05/30/2026
Certification Date: 05/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 LAUREL ST PMB 531
SAN DIEGO CA
92101
US

IV. Provider business mailing address

415 LAUREL ST PMB 531
SAN DIEGO CA
92101-1605
US

V. Phone/Fax

Practice location:
  • Phone: 619-755-4737
  • Fax:
Mailing address:
  • Phone: 619-755-4737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-LIADFM
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License NumberDB365140CB
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number23070
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number7506073033
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: