Healthcare Provider Details

I. General information

NPI: 1326440710
Provider Name (Legal Business Name): TIMOTHY VALENTINE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2014
Last Update Date: 01/24/2024
Certification Date: 01/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 PONDEROSA
SANTA FE NM
87508-6601
US

IV. Provider business mailing address

2711 PLAZUELA SERENA
SANTA FE NM
87505-5270
US

V. Phone/Fax

Practice location:
  • Phone: 505-426-4030
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0169211
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: