Basic Information
| Provider Information | |||||||||
| NPI: | 1689294415 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VILLANOVA | ||||||||
| FirstName: | MICHELE | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | VILLANOVA | ||||||||
| OtherFirstName: | MICHELE | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 79 GLENRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | GLENVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 123024523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5189528408 | ||||||||
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| Practice Location | |||||||||
| Address1: | 21 OLD ROUTE 6 | ||||||||
| Address2: | |||||||||
| City: | CARMEL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105122107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452255202 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2020 | ||||||||
| LastUpdateDate: | 05/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 36554 | NY | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | P109496 | NY | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 01420795 | 05 | NY | MEDICAID |