Provider Demographics
NPI:1750059499
Name:VALDEZ, KATHRYN MARIA-JEAN
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MARIA-JEAN
Last Name:VALDEZ
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 1:1505 W SAINT MARYS RD # 209
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85745-3107
Mailing Address - Country:US
Mailing Address - Phone:844-333-6642
Mailing Address - Fax:520-333-3060
Practice Address - Street 1:1505 W SAINT MARYS RD # 209
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745-3107
Practice Address - Country:US
Practice Address - Phone:844-333-6642
Practice Address - Fax:520-333-3060
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ19-94734106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ47-2615557Medicaid