Provider Demographics
NPI:1154649390
Name:VILLANUEVA, DIVINA THEODOSIA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DIVINA
Middle Name:THEODOSIA
Last Name:VILLANUEVA
Suffix:
Gender:F
Credentials:PSYD
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 155
Mailing Address - Street 2:
Mailing Address - City:MORRO BAY
Mailing Address - State:CA
Mailing Address - Zip Code:93443-0155
Mailing Address - Country:US
Mailing Address - Phone:775-722-2969
Mailing Address - Fax:
Practice Address - Street 1:600 MORRO BAY BLVD UNIT 101
Practice Address - Street 2:
Practice Address - City:MORRO BAY
Practice Address - State:CA
Practice Address - Zip Code:93442-1953
Practice Address - Country:US
Practice Address - Phone:775-722-2969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-12
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY30361103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical