Provider Demographics
NPI:1831432491
Name:VALTIERRA, MARY (PHD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:VALTIERRA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2830 I ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-4311
Mailing Address - Country:US
Mailing Address - Phone:916-456-2011
Mailing Address - Fax:
Practice Address - Street 1:2830 I ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-4311
Practice Address - Country:US
Practice Address - Phone:916-456-2011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-02
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12184103TC0700X, 103TP0814X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical