Provider Demographics
NPI:1083202238
Name:VILLANUEVA, JUAN WAHL BANIS
Entity Type:Individual
Prefix:
First Name:JUAN WAHL
Middle Name:BANIS
Last Name:VILLANUEVA
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:PO BOX 892718
Mailing Address - Street 2:
Mailing Address - City:MILILANI
Mailing Address - State:HI
Mailing Address - Zip Code:96789-8332
Mailing Address - Country:US
Mailing Address - Phone:808-725-9275
Mailing Address - Fax:
Practice Address - Street 1:92-099 LEIPAPA WAY
Practice Address - Street 2:
Practice Address - City:KAPOLEI
Practice Address - State:HI
Practice Address - Zip Code:96707-1343
Practice Address - Country:US
Practice Address - Phone:808-725-9275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-04
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician