Provider Demographics
NPI:1053080564
Name:VILLASENOR, IVAN
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:VILLASENOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2725 FAIR OAKS AVE
Mailing Address - Street 2:
Mailing Address - City:ALTADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91001-4753
Mailing Address - Country:US
Mailing Address - Phone:562-726-8193
Mailing Address - Fax:
Practice Address - Street 1:1230 N MARENGO AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91103-2217
Practice Address - Country:US
Practice Address - Phone:626-797-1124
Practice Address - Fax:626-398-9674
Is Sole Proprietor?:No
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)