Provider Demographics
NPI:1245927540
Name:VALDEZ, JOSE MOISES (SUDRC)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:MOISES
Last Name:VALDEZ
Suffix:
Gender:M
Credentials:SUDRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MACDONALD AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94801-2934
Mailing Address - Country:US
Mailing Address - Phone:510-680-0069
Mailing Address - Fax:
Practice Address - Street 1:603 D ST
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-3719
Practice Address - Country:US
Practice Address - Phone:415-454-9444
Practice Address - Fax:415-454-4864
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14953101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty