Provider Demographics
NPI:1336109487
Name:VILLENA, YOLANDA MARY (PHD)
Entity Type:Individual
Prefix:DR
First Name:YOLANDA
Middle Name:MARY
Last Name:VILLENA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:182 ST JOHNS PLACE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217-3402
Mailing Address - Country:US
Mailing Address - Phone:917-612-8307
Mailing Address - Fax:718-230-0464
Practice Address - Street 1:829 PRESIDENT STREET
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-1405
Practice Address - Country:US
Practice Address - Phone:718-638-8015
Practice Address - Fax:718-230-0464
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2008-05-27
Deactivation Date:2006-12-13
Deactivation Code:
Reactivation Date:2007-05-21
Provider Licenses
StateLicense IDTaxonomies
NY012012103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01475290Medicaid
NYV07651Medicare PIN
S23984Medicare UPIN