Provider Demographics
NPI:1275989980
Name:VILLETA, STACEY DAYMARA (MHC)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:DAYMARA
Last Name:VILLETA
Suffix:
Gender:F
Credentials:MHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 SICKLES ST APT 2C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10040-1641
Mailing Address - Country:US
Mailing Address - Phone:917-515-4748
Mailing Address - Fax:
Practice Address - Street 1:590 AVENUE OF THE AMERICAS FL 7
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-2022
Practice Address - Country:US
Practice Address - Phone:646-784-5110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-11
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP95984101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health