Provider Demographics
NPI:1952874356
Name:VALLECILLOS, ANA IVETTE
Entity Type:Individual
Prefix:
First Name:ANA
Middle Name:IVETTE
Last Name:VALLECILLOS
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 1:426 S COTTONWOOD ST
Mailing Address - Street 2:
Mailing Address - City:EMPORIA
Mailing Address - State:KS
Mailing Address - Zip Code:66801-4848
Mailing Address - Country:US
Mailing Address - Phone:620-757-9399
Mailing Address - Fax:
Practice Address - Street 1:426 S COTTONWOOD ST
Practice Address - Street 2:
Practice Address - City:EMPORIA
Practice Address - State:KS
Practice Address - Zip Code:66801-4848
Practice Address - Country:US
Practice Address - Phone:620-757-9399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KST-LPC3356101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
KST-LPC3356Medicaid