Basic Information
| Provider Information | |||||||||
| NPI: | 1760800130 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ZILLMER | ||||||||
| FirstName: | VALINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 CENTRAL AVE | ||||||||
| Address2: | SUITE E1 | ||||||||
| City: | LAKE ELSINORE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925302740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9514711426 | ||||||||
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| Practice Location | |||||||||
| Address1: | 600 CENTRAL AVE | ||||||||
| Address2: | SUITE E1 | ||||||||
| City: | LAKE ELSINORE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925302740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9514711426 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2014 | ||||||||
| LastUpdateDate: | 07/20/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 79397 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | #95-2633765 | 01 | CA | MEDI-CAL | OTHER |