Provider Demographics
NPI:1801438742
Name:VALDIVIESO, SHALOM (ABAT)
Entity type:Individual
Prefix:
First Name:SHALOM
Middle Name:
Last Name:VALDIVIESO
Suffix:
Gender:F
Credentials:ABAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1360 S ANAHEIM BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-6205
Mailing Address - Country:US
Mailing Address - Phone:714-948-7641
Mailing Address - Fax:714-689-1381
Practice Address - Street 1:1360 S ANAHEIM BLVD STE 101
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-6205
Practice Address - Country:US
Practice Address - Phone:714-948-7641
Practice Address - Fax:714-689-1381
Is Sole Proprietor?:No
Enumeration Date:2019-10-11
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator