Healthcare Provider Details

I. General information

NPI: 1831459023
Provider Name (Legal Business Name): REBECCA KOSTURA VIDAK M.S.W., L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2012
Last Update Date: 05/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 WASHINGTON RD GROUND FLOOR ROOM 2
MC MURRAY PA
15317-2534
US

IV. Provider business mailing address

6425 INTERLAKEN DR
MC DONALD PA
15057-3557
US

V. Phone/Fax

Practice location:
  • Phone: 412-427-0497
  • Fax:
Mailing address:
  • Phone: 412-427-0497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW015058
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: