Provider Demographics
NPI:1114389475
Name:VILLALTA, YESENIA
Entity Type:Individual
Prefix:
First Name:YESENIA
Middle Name:
Last Name:VILLALTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14321 WINTER BREEZE DR # 50
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-2452
Mailing Address - Country:US
Mailing Address - Phone:571-317-1833
Mailing Address - Fax:
Practice Address - Street 1:14321 WINTER BREEZE DR # 50
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-2452
Practice Address - Country:US
Practice Address - Phone:571-317-1833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-25
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA600876329Medicaid