Provider Demographics
NPI:1265699987
Name:VALDERRAMA, RANDY
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:VALDERRAMA
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 1:1212 S 43RD ST
Mailing Address - Street 2:SUITE#C
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92113-3454
Mailing Address - Country:US
Mailing Address - Phone:619-263-7768
Mailing Address - Fax:619-262-5040
Practice Address - Street 1:1212 S 43RD ST
Practice Address - Street 2:SUITE#C
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92113-3454
Practice Address - Country:US
Practice Address - Phone:619-263-7768
Practice Address - Fax:619-262-5040
Is Sole Proprietor?:No
Enumeration Date:2008-05-20
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)