Provider Demographics
NPI:1942328406
Name:VALDIVIESO, DEBORAH
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:VALDIVIESO
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 1:1022 FLORIDA AVE S
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-2145
Mailing Address - Country:US
Mailing Address - Phone:321-634-3688
Mailing Address - Fax:321-504-0955
Practice Address - Street 1:1022 FLORIDA AVE S
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2145
Practice Address - Country:US
Practice Address - Phone:321-634-3688
Practice Address - Fax:321-504-0955
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT3790225100000X, 222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL882160700Medicaid
FL889522800Medicaid