Provider Demographics
NPI:1659642692
Name:VALDEZ, PHILIP MICHAEL (LMFT)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:MICHAEL
Last Name:VALDEZ
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24062 S ISAAC LAKE LN
Mailing Address - Street 2:
Mailing Address - City:BOVEY
Mailing Address - State:MN
Mailing Address - Zip Code:55709-7046
Mailing Address - Country:US
Mailing Address - Phone:213-842-0821
Mailing Address - Fax:
Practice Address - Street 1:413 SE 13TH ST
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-0015
Practice Address - Country:US
Practice Address - Phone:218-999-9908
Practice Address - Fax:218-999-9959
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-23
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52261106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA52261OtherLICENSE NUMBER