Provider Demographics
NPI:1235250374
Name:VILLEGAS, TERESITA (CCC-A)
Entity Type:Individual
Prefix:MRS
First Name:TERESITA
Middle Name:
Last Name:VILLEGAS
Suffix:
Gender:F
Credentials:CCC-A
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 5455
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30154
Mailing Address - Country:US
Mailing Address - Phone:770-714-8644
Mailing Address - Fax:678-505-8012
Practice Address - Street 1:3776 HIGHWAY 5
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-3368
Practice Address - Country:US
Practice Address - Phone:770-714-8644
Practice Address - Fax:678-505-8012
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAUD003145231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000804757AMedicaid