Provider Demographics
NPI:1336503200
Name:VILLA, MARCIA G (MS LPC-IT, SAC-IT)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:G
Last Name:VILLA
Suffix:
Gender:F
Credentials:MS LPC-IT, SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1028 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53204-1335
Mailing Address - Country:US
Mailing Address - Phone:414-643-8530
Mailing Address - Fax:
Practice Address - Street 1:1111 S 6TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-2301
Practice Address - Country:US
Practice Address - Phone:414-643-8530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-07
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3497 - 226101YP2500X
WI17620101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional