Provider Demographics
NPI:1053854695
Name:VALENZUELA, GLENDA
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:
Last Name:VALENZUELA
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 1:1963 N E ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92405-3919
Mailing Address - Country:US
Mailing Address - Phone:909-881-6146
Mailing Address - Fax:
Practice Address - Street 1:1963 N E ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92405-3919
Practice Address - Country:US
Practice Address - Phone:909-881-6146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-30
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACICA00221118101YA0400X
CA164409 II101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)