Provider Demographics
NPI:1770368292
Name:VILLANUEVA, MATT G (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:MATT
Middle Name:G
Last Name:VILLANUEVA
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 LAS PALMAS DR
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92602-2319
Mailing Address - Country:US
Mailing Address - Phone:760-774-7155
Mailing Address - Fax:
Practice Address - Street 1:3851 KATELLA AVE STE 365
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3392
Practice Address - Country:US
Practice Address - Phone:562-296-8107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-31
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA304678225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist