Provider Demographics
NPI:1558124651
Name:VALDIVIA, MICHELLE J
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:J
Last Name:VALDIVIA
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 1:15704 JONES LN
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20878-3563
Mailing Address - Country:US
Mailing Address - Phone:949-697-4181
Mailing Address - Fax:
Practice Address - Street 1:7979 OLD GEORGETOWN RD FL 1
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-2429
Practice Address - Country:US
Practice Address - Phone:301-664-9664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-01
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD291721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty