Healthcare Provider Details

I. General information

NPI: 1053285387
Provider Name (Legal Business Name): VALERIE S NIETO RADT I
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2025
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7150 BROADWAY
LEMON GROVE CA
91945-1401
US

IV. Provider business mailing address

1425 SECOND AVE SPC 113
CHULA VISTA CA
91911-5017
US

V. Phone/Fax

Practice location:
  • Phone: 619-255-5167
  • Fax:
Mailing address:
  • Phone: 619-255-5167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1620540725
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: