Healthcare Provider Details

I. General information

NPI: 1801578752
Provider Name (Legal Business Name): DAVID TYLER VALENTINE CCMA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2023
Last Update Date: 08/01/2023
Certification Date: 09/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6048 S DURANGO DR
LAS VEGAS NV
89113-1781
US

IV. Provider business mailing address

6445 PEARTREE RD
LAS VEGAS NV
89108-4406
US

V. Phone/Fax

Practice location:
  • Phone: 702-815-1550
  • Fax: 702-815-1554
Mailing address:
  • Phone: 725-249-5891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License NumberJ5M6H2Q9
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: