Provider Demographics
NPI:1982334710
Name:VILLAGOMEZ PULIDO, MARIA DE JESUS DALIA
Entity Type:Individual
Prefix:
First Name:MARIA DE JESUS
Middle Name:DALIA
Last Name:VILLAGOMEZ PULIDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2225 CHALLENGER WAY
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-5441
Mailing Address - Country:US
Mailing Address - Phone:707-576-8181
Mailing Address - Fax:707-565-5183
Practice Address - Street 1:2225 CHALLENGER WAY
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-5441
Practice Address - Country:US
Practice Address - Phone:707-576-8181
Practice Address - Fax:707-565-5183
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-14
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YP2500X
CA142146106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional