Provider Demographics
NPI:1366910275
Name:VALADEZ, DANIEL GUSTAVO
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:GUSTAVO
Last Name:VALADEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243-3013
Mailing Address - Country:US
Mailing Address - Phone:760-482-0864
Mailing Address - Fax:760-482-9185
Practice Address - Street 1:200 S 5TH ST
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-3013
Practice Address - Country:US
Practice Address - Phone:760-482-0864
Practice Address - Fax:760-482-9185
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-08
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1649473695Medicaid