Basic Information
| Provider Information | |||||||||
| NPI: | 1215426960 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VIDAL | ||||||||
| FirstName: | NISSA-BELLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 848 REYANA WAY | ||||||||
| Address2: | |||||||||
| City: | PERRIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925715115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9519702651 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4952 WARNER AVE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926494479 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145879007 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2018 | ||||||||
| LastUpdateDate: | 07/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | 17-30402 | CA | N | 103K00000X | 1-19-39870 | CA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.