Basic Information
| Provider Information | |||||||||
| NPI: | 1295209401 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VALDEZ | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 854 GLENEAGLES AVE | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917681183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6266241396 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2750 E WASHINGTON BLVD STE 230 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911071449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262968900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2019 | ||||||||
| LastUpdateDate: | 05/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 171M00000X | CA | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.