Provider Demographics
NPI:1346568920
Name:VALDES, GERRY
Entity Type:Individual
Prefix:MR
First Name:GERRY
Middle Name:
Last Name:VALDES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 S EREMLAND DR
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-3186
Mailing Address - Country:US
Mailing Address - Phone:626-966-1577
Mailing Address - Fax:626-966-1584
Practice Address - Street 1:2180 VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91768-3325
Practice Address - Country:US
Practice Address - Phone:909-865-2336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARS5862101Y00000X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARS5862OtherINTERCOAST COLLEGE