Provider Demographics
NPI:1447946363
Name:VIDAL REYES, LETICIA (CBHCM)
Entity type:Individual
Prefix:
First Name:LETICIA
Middle Name:
Last Name:VIDAL REYES
Suffix:
Gender:F
Credentials:CBHCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8889 FONTAINEBLEAU BLVD APT 309
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33172-4445
Mailing Address - Country:US
Mailing Address - Phone:678-907-0469
Mailing Address - Fax:
Practice Address - Street 1:10520 NW 26TH ST STE C201C202
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33172-5940
Practice Address - Country:US
Practice Address - Phone:786-704-6657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-13
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator