Healthcare Provider Details

I. General information

NPI: 1285199331
Provider Name (Legal Business Name): JULIO VIDAL PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2019
Last Update Date: 02/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 PROVIDENCE AVE
CHESTER PA
19013-5218
US

IV. Provider business mailing address

2201 PROVIDENCE AVE
CHESTER PA
19013-5218
US

V. Phone/Fax

Practice location:
  • Phone: 610-872-9101
  • Fax:
Mailing address:
  • Phone: 610-872-9101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS018737
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: