=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457913139
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIDA COUNSELING INCORPORATED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2019
-----------------------------------------------------
Last Update Date | 07/02/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4962 ANCIENT ELM
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78247-5668
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-445-0914
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4962 ANCIENT ELM
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78247-5668
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | EVELYN LEON
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 210-445-0914
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------