Healthcare Provider Details

I. General information

NPI: 1497085492
Provider Name (Legal Business Name): DANIEL P VIDEC LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2010
Last Update Date: 01/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 S COURT ST SUITE 5
MEDINA OH
44256-2275
US

IV. Provider business mailing address

230 S COURT ST SUITE 5
MEDINA OH
44256-2275
US

V. Phone/Fax

Practice location:
  • Phone: 330-723-7997
  • Fax: 330-725-5177
Mailing address:
  • Phone: 330-723-7997
  • Fax: 330-725-5177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.0901029
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: