Provider Demographics
NPI:1679860084
Name:VILLATORO, MIRNA G (RDHAP)
Entity Type:Individual
Prefix:
First Name:MIRNA
Middle Name:G
Last Name:VILLATORO
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11100 SEPULVEDA BLVD
Mailing Address - Street 2:# 232
Mailing Address - City:MISSION HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91345
Mailing Address - Country:US
Mailing Address - Phone:818-388-3917
Mailing Address - Fax:818-810-5489
Practice Address - Street 1:11100 SEPULVEDA BLVD
Practice Address - Street 2:# 232
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345
Practice Address - Country:US
Practice Address - Phone:818-388-3917
Practice Address - Fax:818-810-5489
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-06
Last Update Date:2011-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDHAP 351320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities