Provider Demographics
NPI:1770148603
Name:VILLANUEVA, CLARITO DIMACALI JR
Entity type:Individual
Prefix:MR
First Name:CLARITO
Middle Name:DIMACALI
Last Name:VILLANUEVA
Suffix:JR
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 1:4027 YORK BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90065-3720
Mailing Address - Country:US
Mailing Address - Phone:213-268-5296
Mailing Address - Fax:
Practice Address - Street 1:25000 AVENUE STANFORD
Practice Address - Street 2:
Practice Address - City:SANTA CLARITA
Practice Address - State:CA
Practice Address - Zip Code:91355-1224
Practice Address - Country:US
Practice Address - Phone:818-600-2034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-06
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA770232163WP0808X
CA95013359363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health