Provider Demographics
NPI:1770168510
Name:VILLA, ELIZABETH GUADALUPE (AA)
Entity type:Individual
Prefix:MISS
First Name:ELIZABETH
Middle Name:GUADALUPE
Last Name:VILLA
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 SPRUCE ST STE 250
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-7429
Mailing Address - Country:US
Mailing Address - Phone:760-815-7772
Mailing Address - Fax:
Practice Address - Street 1:1650 SPRUCE ST STE 250
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-7429
Practice Address - Country:US
Practice Address - Phone:760-815-7772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-12
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician