Provider Demographics
NPI:1114585338
Name:VALDEZ-YAKUTA, THANIA
Entity Type:Individual
Prefix:
First Name:THANIA
Middle Name:
Last Name:VALDEZ-YAKUTA
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 1:950 N STATE ST STE E
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-1485
Mailing Address - Country:US
Mailing Address - Phone:951-654-2026
Mailing Address - Fax:
Practice Address - Street 1:950 N STATE ST STE E
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-1485
Practice Address - Country:US
Practice Address - Phone:951-654-2026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-03
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
R1350340619101YA0400X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program