1609455203 NPI number — MADONNA GRACE MENDOZA VALDEZ BCBA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609455203 NPI number — MADONNA GRACE MENDOZA VALDEZ BCBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VALDEZ
Provider First Name:
MADONNA GRACE
Provider Middle Name:
MENDOZA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BCBA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MENDOZA
Provider Other First Name:
MADONNA GRACE
Provider Other Middle Name:
PEREZ
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
BCBA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1609455203
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2 VILLAGE SQ STE 210
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21210-1624
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
609-525-4271
Provider Business Mailing Address Fax Number:
443-743-3863

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
648 INDEPENDENCE PKWY STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHESAPEAKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23320-5208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-565-7222
Provider Business Practice Location Address Fax Number:
877-734-1914
Provider Enumeration Date:
04/02/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  1-17-24991 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1609455203 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com