Provider Demographics
NPI:1083726236
Name:VILLANUEVA, KRISTINE A (LCSW)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:A
Last Name:VILLANUEVA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2695 12TH PL SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-2537
Mailing Address - Country:US
Mailing Address - Phone:503-999-5971
Mailing Address - Fax:503-391-7422
Practice Address - Street 1:4035 12TH ST. CUT OFF SE
Practice Address - Street 2:SUITE 140
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302
Practice Address - Country:US
Practice Address - Phone:503-999-5971
Practice Address - Fax:503-391-7422
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2633101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR112836Medicare ID - Type Unspecified