Provider Demographics
NPI:1497952766
Name:VILLAMARIN, EDGAR GUSTAVO (MFT)
Entity Type:Individual
Prefix:MR
First Name:EDGAR
Middle Name:GUSTAVO
Last Name:VILLAMARIN
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:485 CASTANO AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-2807
Mailing Address - Country:US
Mailing Address - Phone:626-577-5097
Mailing Address - Fax:
Practice Address - Street 1:1200 WILSHIRE BLVD
Practice Address - Street 2:SUITE 500
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1908
Practice Address - Country:US
Practice Address - Phone:213-481-7464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT18116106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist