Provider Demographics
NPI:1881372845
Name:VILLA, JIMI (RADT I)
Entity type:Individual
Prefix:MR
First Name:JIMI
Middle Name:
Last Name:VILLA
Suffix:
Gender:M
Credentials:RADT I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2542 E 218TH PL
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90810-1703
Mailing Address - Country:US
Mailing Address - Phone:310-924-8226
Mailing Address - Fax:
Practice Address - Street 1:1207 E FRUIT ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4296
Practice Address - Country:US
Practice Address - Phone:714-953-9373
Practice Address - Fax:714-953-7573
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-10
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1509010523101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)