Provider Demographics
NPI:1518242387
Name:VALDES, DOMINIC PATRICK (LCSW)
Entity Type:Individual
Prefix:MR
First Name:DOMINIC
Middle Name:PATRICK
Last Name:VALDES
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 S MAIN ST #PH204
Mailing Address - Street 2:#PH204
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90014
Mailing Address - Country:US
Mailing Address - Phone:562-400-8133
Mailing Address - Fax:
Practice Address - Street 1:22669 PACIFIC COAST HWY
Practice Address - Street 2:
Practice Address - City:MALIBU
Practice Address - State:CA
Practice Address - Zip Code:90265-5036
Practice Address - Country:US
Practice Address - Phone:562-400-8133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-12
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW30539101YM0800X
CA305391041C0700X
CA710101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health