Provider Demographics
NPI:1710575790
Name:VALDES, EZEQUIEL SR
Entity Type:Individual
Prefix:
First Name:EZEQUIEL
Middle Name:
Last Name:VALDES
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4707 140TH AVE N STE 309
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33762-3840
Mailing Address - Country:US
Mailing Address - Phone:813-850-2197
Mailing Address - Fax:
Practice Address - Street 1:4707 140TH AVE N STE 309
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33762-3840
Practice Address - Country:US
Practice Address - Phone:813-850-2197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-06
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician