Provider Demographics
NPI:1801161666
Name:CARRERA VALDES, IVIS M
Entity type:Individual
Prefix:MS
First Name:IVIS
Middle Name:M
Last Name:CARRERA VALDES
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 1:2005 THRACE ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33605-6353
Mailing Address - Country:US
Mailing Address - Phone:813-562-4391
Mailing Address - Fax:
Practice Address - Street 1:1501 S PINELLAS AVE STE P
Practice Address - Street 2:
Practice Address - City:TARPON SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34689-1952
Practice Address - Country:US
Practice Address - Phone:727-547-3692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-13
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
FLIMH19960101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist