Provider Demographics
NPI:1801624598
Name:VILLA, MARTIN VINCENT (LMFT)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:VINCENT
Last Name:VILLA
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:MARTY
Other - Middle Name:VINCENT
Other - Last Name:VILLA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2361 SCENIC DR
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-4504
Mailing Address - Country:US
Mailing Address - Phone:209-597-3311
Mailing Address - Fax:209-783-8717
Practice Address - Street 1:2361 SCENIC DR
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-4504
Practice Address - Country:US
Practice Address - Phone:209-597-3311
Practice Address - Fax:209-783-8717
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-24
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52861106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist