Provider Demographics
NPI:1790160794
Name:VILLALTA, KEVIN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:VILLALTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 93606
Mailing Address - Street 2:
Mailing Address - City:CITY OF INDUSTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91715-3606
Mailing Address - Country:US
Mailing Address - Phone:818-577-3892
Mailing Address - Fax:
Practice Address - Street 1:11721 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:SANTA FE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:90670-3674
Practice Address - Country:US
Practice Address - Phone:562-949-8455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-21
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW71678101YM0800X
CAASW107795101YM0800X
171M00000X, 390200000X
CA1127161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program