Provider Demographics
NPI:1649767021
Name:VILLASENOR, DONNA ANDREA
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:ANDREA
Last Name:VILLASENOR
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 1:658 E BRIER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-2847
Mailing Address - Country:US
Mailing Address - Phone:909-501-0700
Mailing Address - Fax:909-387-7611
Practice Address - Street 1:658 E BRIER DRIVE SUITE 200
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92415-2499
Practice Address - Country:US
Practice Address - Phone:909-501-0700
Practice Address - Fax:909-387-7611
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-20
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAASW98655101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program