Provider Demographics
NPI:1467018580
Name:VILLA, CRYSTAL
Entity Type:Individual
Prefix:MISS
First Name:CRYSTAL
Middle Name:
Last Name:VILLA
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 1:29768 DAWNCREST CIR
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-1878
Mailing Address - Country:US
Mailing Address - Phone:760-682-8076
Mailing Address - Fax:
Practice Address - Street 1:41661 ENTERPRISE CIR N STE 121
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-5629
Practice Address - Country:US
Practice Address - Phone:951-587-4165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-14
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA1179221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician