MEDICARE: GIOVANNI MARTIN VALDIVIA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	82877	TX

General Provider Information

NPI Number	:	1215674122
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GIOVANNI MARTIN VALDIVIA

Provider Business Mailing Address
First Line	:	2314 KEEGAN HOLLOW LN
Second Line	:
City	:	SPRING
State	:	TX
Zip	:	77386-3325
Country	:	US
Telephone Number	:	214-995-4272
Fax Number	:

Provider Business Practice Location Address
First Line	:	25325 BOROUGH PARK DR STE 220
Second Line	:
City	:	THE WOODLANDS
State	:	TX
Zip	:	77380-3564
Country	:	US
Telephone Number	:	936-777-3940
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/13/2022
Last Update Date	:	05/13/2022

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