Healthcare Provider Details

I. General information

NPI: 1619376845
Provider Name (Legal Business Name): FELIZON VIDAD PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2014
Last Update Date: 05/04/2022
Certification Date: 05/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HIGHWAY 1 N
SAN LUIS OBISPO CA
93409-8101
US

IV. Provider business mailing address

PO BOX 23423
VENTURA CA
93002-3423
US

V. Phone/Fax

Practice location:
  • Phone: 805-547-7900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY24711
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: