Basic Information
| Provider Information | |||||||||
| NPI: | 1073130993 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VILLA | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCDC III | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7205 MENTOR AVE APT C104 | ||||||||
| Address2: | |||||||||
| City: | MENTOR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440607550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4406228844 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1320 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441132333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2167810550 | ||||||||
| FaxNumber: | 2157272987 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2020 | ||||||||
| LastUpdateDate: | 06/26/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 071022 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.