Provider Demographics
NPI:1881493880
Name:VIDAL, ANTONIO VALENTINO (BACB1273321)
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:VALENTINO
Last Name:VIDAL
Suffix:
Gender:M
Credentials:BACB1273321
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 FONTAINEBLEAU BLVD APT 305
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33172-4571
Mailing Address - Country:US
Mailing Address - Phone:786-830-1797
Mailing Address - Fax:
Practice Address - Street 1:110 FONTAINEBLEAU BLVD APT 305
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33172-4571
Practice Address - Country:US
Practice Address - Phone:786-830-1797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-11
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1273321106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician