Provider Demographics
NPI:1679048417
Name:VALDIVIA, TAYLOR NICOLE NANQUIL (MA, LMFT)
Entity type:Individual
Prefix:
First Name:TAYLOR NICOLE
Middle Name:NANQUIL
Last Name:VALDIVIA
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 301
Mailing Address - Street 2:
Mailing Address - City:BONITA
Mailing Address - State:CA
Mailing Address - Zip Code:91908-0301
Mailing Address - Country:US
Mailing Address - Phone:619-773-5673
Mailing Address - Fax:
Practice Address - Street 1:6244 EL CAJON BLVD STE 14
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-3918
Practice Address - Country:US
Practice Address - Phone:619-481-3790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-08
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA109585106H00000X
CA122016106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist