Basic Information
| Provider Information | |||||||||
| NPI: | 1346906310 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VILLAVERDE COUNSELING AND WELLNESS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2960 WINEGAR RD | ||||||||
| Address2: | |||||||||
| City: | BANCROFT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484149756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173034185 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2960 WINEGAR RD | ||||||||
| Address2: | |||||||||
| City: | BANCROFT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484149756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173034185 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2021 | ||||||||
| LastUpdateDate: | 11/13/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HERNANDEZ | ||||||||
| AuthorizedOfficialFirstName: | ANGELICA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9893274744 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LPC | ||||||||
| NPICertificationDate: | 11/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 6401011899 | 01 | MI | LICENSE NUMBER | OTHER |