Provider Demographics
NPI:1417477365
Name:VILLANUEVA, FAITH INTERVALO (ATC)
Entity Type:Individual
Prefix:MS
First Name:FAITH
Middle Name:INTERVALO
Last Name:VILLANUEVA
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9017 SYCAMORE AVE UNIT 212
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-5609
Mailing Address - Country:US
Mailing Address - Phone:714-290-5749
Mailing Address - Fax:
Practice Address - Street 1:100 DIAMOND RANCH RD
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766-4723
Practice Address - Country:US
Practice Address - Phone:909-397-4715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-21
Last Update Date:2017-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty