Provider Demographics
NPI:1548816960
Name:BEDREGAL VALDIVIA, VANESSA ANGELA
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:ANGELA
Last Name:BEDREGAL VALDIVIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3756 SANTA ROSALIA DR STE 628
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90008-3606
Mailing Address - Country:US
Mailing Address - Phone:323-293-8771
Mailing Address - Fax:
Practice Address - Street 1:4000 W METROPOLITAN DR STE 400
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3503
Practice Address - Country:US
Practice Address - Phone:855-625-4657
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-12
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT115901101YM0800X
106S00000X, 106H00000X
115901106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician