Healthcare Provider Details

I. General information

NPI: 1669770426
Provider Name (Legal Business Name): DAVID GREGORY VALLEY CSAC, CLA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2011
Last Update Date: 06/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3258 NORTH STATE STREET
UKIAH CA
95482-3052
US

IV. Provider business mailing address

3258 NORTH STATE STREET
UKIAH CA
95482-3052
US

V. Phone/Fax

Practice location:
  • Phone: 707-234-9472
  • Fax: 707-463-2045
Mailing address:
  • Phone: 707-234-9472
  • Fax: 707-463-2045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number1135-031613A
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCORPHQ-1135-031613A
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1135-031613A
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: