Healthcare Provider Details

I. General information

NPI: 1194662015
Provider Name (Legal Business Name): ASTRID VANESSA PALENCIA VALLAR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2026
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2580 FRUITVALE AVE APT B
OAKLAND CA
94601-1964
US

IV. Provider business mailing address

1075 CREEKSIDE RIDGE DR STE 280
ROSEVILLE CA
95678-3504
US

V. Phone/Fax

Practice location:
  • Phone: 510-282-6836
  • Fax:
Mailing address:
  • Phone: 510-282-6836
  • Fax: 510-282-6836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberY9020774
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: