Provider Demographics
NPI:1245460070
Name:VALDIVIA-MAIRESSE, WILLIAM (PSYD)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:
Last Name:VALDIVIA-MAIRESSE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12400 WILSHIRE BLVD
Mailing Address - Street 2:STE. 230
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1019
Mailing Address - Country:US
Mailing Address - Phone:424-229-1838
Mailing Address - Fax:310-399-9358
Practice Address - Street 1:12400 WILSHIRE BLVD
Practice Address - Street 2:STE. 230
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1019
Practice Address - Country:US
Practice Address - Phone:424-229-1838
Practice Address - Fax:310-399-9358
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-14
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY24368103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist