Basic Information
| Provider Information | |||||||||
| NPI: | 1639520638 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | VILLANUEVA | ||||||||
| FirstName: | HAZEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6667 WILBUR AVE UNIT 36 | ||||||||
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| City: | RESEDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913355170 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8186489106 | ||||||||
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| Practice Location | |||||||||
| Address1: | 16260 VENTURA BLVD STE 600 | ||||||||
| Address2: | |||||||||
| City: | ENCINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914364604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189861977 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2016 | ||||||||
| LastUpdateDate: | 06/30/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 9807 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 953995050 | 05 | CA | MEDICAID |