Provider Demographics
NPI:1104593805
Name:VALDERRAMA, DENISE FRANCES
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:FRANCES
Last Name:VALDERRAMA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3550 TROPHY DR
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-8039
Mailing Address - Country:US
Mailing Address - Phone:619-962-9211
Mailing Address - Fax:
Practice Address - Street 1:2701 MIDWAY DRIVE
Practice Address - Street 2:UNIT 371141
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92137
Practice Address - Country:US
Practice Address - Phone:619-962-9211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-21-50142103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL475085623OtherTRICARE