Provider Demographics
NPI:1710245139
Name:VALENTINE, MICKIE LYNETTE (MA)
Entity Type:Individual
Prefix:MS
First Name:MICKIE
Middle Name:LYNETTE
Last Name:VALENTINE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4460 W SHAW AVE STE 274
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93722-6210
Mailing Address - Country:US
Mailing Address - Phone:559-977-7554
Mailing Address - Fax:877-355-7918
Practice Address - Street 1:1424 W CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93706-3922
Practice Address - Country:US
Practice Address - Phone:559-795-0900
Practice Address - Fax:559-795-0901
Is Sole Proprietor?:No
Enumeration Date:2012-04-24
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF91591106H00000X
CAIMF 62546106H00000X
CA125875106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist