Provider Demographics
NPI:1154813475
Name:VILLALOBOS, BRENDA ESMERALDA
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:ESMERALDA
Last Name:VILLALOBOS
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 1:16950 GRAMERCY PL SPC 67A
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-5236
Mailing Address - Country:US
Mailing Address - Phone:310-903-6928
Mailing Address - Fax:
Practice Address - Street 1:1901 E CENTER ST
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-3457
Practice Address - Country:US
Practice Address - Phone:714-780-0750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-01
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00000Medicaid