Provider Demographics
NPI:1609400993
Name:VILLA, STACEY (MED)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:VILLA
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 MEDICAL CENTER DR STE B1
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-5002
Mailing Address - Country:US
Mailing Address - Phone:915-845-3122
Mailing Address - Fax:915-845-4165
Practice Address - Street 1:1600 MEDICAL CENTER DR STE B1
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-5002
Practice Address - Country:US
Practice Address - Phone:915-845-3122
Practice Address - Fax:915-845-4165
Is Sole Proprietor?:No
Enumeration Date:2020-02-26
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX78781101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional