Provider Demographics
NPI:1407254394
Name:VALLECALLE, CAROL
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:VALLECALLE
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:INTERMOUNTAIN CENTERS FOR HUMAN DEVELOPMENT INC
Mailing Address - Street 2:994 S HARRISON RD
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85748
Mailing Address - Country:US
Mailing Address - Phone:520-721-1887
Mailing Address - Fax:
Practice Address - Street 1:12119 E. METZ DR
Practice Address - Street 2:
Practice Address - City:VAIL
Practice Address - State:AZ
Practice Address - Zip Code:85641
Practice Address - Country:US
Practice Address - Phone:562-381-5502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-09
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4729270171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor