Organization
VIDA CLINIC PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ALAIN STORDAHL (BUSINESS MANAGER)
(512) 537-7976
Entity
Organization
Contact information
Practice address
1221 W BEN WHITE BLVD STE 210A, AUSTIN, TX 78704-7182
(512) 960-4533
(512) 887-3970
Mailing address
1221 W BEN WHITE BLVD STE 210A, AUSTIN, TX 78704-7182
(512) 960-4533
(512) 887-3970
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
34166
TX
251S00000X
Community/Behavioral Health Agency
34166
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
3572935-01
—
TX
Enumeration date
06/24/2015
Last updated
08/16/2021
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