Basic Information
| Provider Information | |||||||||
| NPI: | 1184903148 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VILLA | ||||||||
| FirstName: | MAIRA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | BA | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 537 W COSTNER ST | ||||||||
| Address2: | |||||||||
| City: | FARMERSVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932231406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5593039174 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3467 W SHAW AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937113223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592713096 | ||||||||
| FaxNumber: | 5592740292 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2011 | ||||||||
| LastUpdateDate: | 10/10/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | 941719862 | CA | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.