Provider Demographics
NPI:1669925384
Name:VILLA, BRIANDA (LCSW 101918)
Entity type:Individual
Prefix:
First Name:BRIANDA
Middle Name:
Last Name:VILLA
Suffix:
Gender:F
Credentials:LCSW 101918
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 1075
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-0075
Mailing Address - Country:US
Mailing Address - Phone:909-247-4651
Mailing Address - Fax:
Practice Address - Street 1:801 CORPORATE CENTER DR STE 202
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91768-2628
Practice Address - Country:US
Practice Address - Phone:909-766-7060
Practice Address - Fax:909-992-3177
Is Sole Proprietor?:No
Enumeration Date:2016-07-28
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1019181041C0700X
CA84566101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1943OtherMEDICAL