Provider Demographics
NPI:1144621897
Name:VALDEZ, KAITLYN NICOLE (MA)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:NICOLE
Last Name:VALDEZ
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:NICOLE
Other - Last Name:VALDEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA
Mailing Address - Street 1:470 CHADBOURNE ROAD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533
Mailing Address - Country:US
Mailing Address - Phone:707-628-8081
Mailing Address - Fax:
Practice Address - Street 1:470 CHADBOURNE RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534-9600
Practice Address - Country:US
Practice Address - Phone:707-628-8081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-12
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF91026101YM0800X
CAPCC12571101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1144621897Medicaid