Basic Information
| Provider Information | |||||||||
| NPI: | 1649767021 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VILLASENOR | ||||||||
| FirstName: | DONNA | ||||||||
| MiddleName: | ANDREA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 780 E GILBERT ST | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924153248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093860776 | ||||||||
| FaxNumber: | 9093877386 | ||||||||
| Practice Location | |||||||||
| Address1: | 15345 BONANZA RD | ||||||||
| Address2: | |||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923922499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9092524070 | ||||||||
| FaxNumber: | 9093877386 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2018 | ||||||||
| LastUpdateDate: | 04/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101YM0800X | ASW98655 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.