Provider Demographics
NPI:1760800130
Name:ZILLMER, VALINE
Entity Type:Individual
Prefix:
First Name:VALINE
Middle Name:
Last Name:ZILLMER
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 1:600 CENTRAL AVE
Mailing Address - Street 2:SUITE E1
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-2740
Mailing Address - Country:US
Mailing Address - Phone:951-471-1426
Mailing Address - Fax:
Practice Address - Street 1:600 CENTRAL AVE
Practice Address - Street 2:SUITE E1
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-2740
Practice Address - Country:US
Practice Address - Phone:951-471-1426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-02
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA79397106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA#95-2633765OtherMEDI-CAL