Provider Demographics
NPI:1790580694
Name:BURGOS VALDERRAMA, YAMARIE MALLIE
Entity type:Individual
Prefix:
First Name:YAMARIE
Middle Name:MALLIE
Last Name:BURGOS VALDERRAMA
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 1:3802 ALBRIGHT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-4032
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:613 OCEAN PARK BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-3713
Practice Address - Country:US
Practice Address - Phone:206-841-6561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-14
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician