Provider Demographics
NPI:1891417374
Name:VALENCIA, GUSTAVO ADOLFO
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:ADOLFO
Last Name:VALENCIA
Suffix:
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 1:1116 N 61ST AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33024-6059
Mailing Address - Country:US
Mailing Address - Phone:954-397-1124
Mailing Address - Fax:
Practice Address - Street 1:1116 N 61ST AVE
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33024-6059
Practice Address - Country:US
Practice Address - Phone:954-397-1124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty