Provider Demographics
NPI:1750478244
Name:VALDEZ, LETICIA MARIE
Entity Type:Individual
Prefix:
First Name:LETICIA
Middle Name:MARIE
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:PO BOX 3125
Mailing Address - Street 2:
Mailing Address - City:ELEVEN MILE CORNER
Mailing Address - State:AZ
Mailing Address - Zip Code:85222-0125
Mailing Address - Country:US
Mailing Address - Phone:520-723-6700
Mailing Address - Fax:520-723-7232
Practice Address - Street 1:1400 N ELEVEN MILE CORNER RD
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85222-9187
Practice Address - Country:US
Practice Address - Phone:520-723-6700
Practice Address - Fax:520-723-7232
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ96512Medicaid