Provider Demographics
NPI:1952958910
Name:VALDIVIA, VICTOR M SR
Entity Type:Individual
Prefix:MR
First Name:VICTOR
Middle Name:M
Last Name:VALDIVIA
Suffix:SR
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 1:12421 SW 10TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33184-2390
Mailing Address - Country:US
Mailing Address - Phone:561-283-6467
Mailing Address - Fax:
Practice Address - Street 1:1414 NW 107TH AVE STE 301
Practice Address - Street 2:
Practice Address - City:SWEETWATER
Practice Address - State:FL
Practice Address - Zip Code:33172-2742
Practice Address - Country:US
Practice Address - Phone:786-860-5161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-23
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician