Provider Demographics
NPI:1326772047
Name:VALENZUELA, KYLIANNA THERESE
Entity Type:Individual
Prefix:
First Name:KYLIANNA
Middle Name:THERESE
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 1:5607 SKIPPING STONE DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-5048
Mailing Address - Country:US
Mailing Address - Phone:317-954-1481
Mailing Address - Fax:
Practice Address - Street 1:5545 E STOP 11 RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-8616
Practice Address - Country:US
Practice Address - Phone:317-960-5437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-11
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN808866106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician