Provider Demographics
NPI:1700279288
Name:VILLA, SUSANA (MC, LPC)
Entity Type:Individual
Prefix:
First Name:SUSANA
Middle Name:
Last Name:VILLA
Suffix:
Gender:F
Credentials:MC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 S STONE AVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85701-1713
Mailing Address - Country:US
Mailing Address - Phone:520-792-3293
Mailing Address - Fax:520-792-4336
Practice Address - Street 1:8050 E LAKESIDE PKWY
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85730-1254
Practice Address - Country:US
Practice Address - Phone:520-584-5820
Practice Address - Fax:520-514-1514
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-09
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-14201101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional