Healthcare Provider Details

I. General information

NPI: 1366116089
Provider Name (Legal Business Name): NATHAN MICHAEL VALENTINE MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2021
Last Update Date: 06/25/2024
Certification Date: 06/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10400 FRICOT CITY RD
SAN ANDREAS CA
95249-9642
US

IV. Provider business mailing address

1085 WESTCREEK LN
CARSON CITY NV
89706-4369
US

V. Phone/Fax

Practice location:
  • Phone: 209-736-4500
  • Fax:
Mailing address:
  • Phone: 925-329-2096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number146042
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: