Basic Information
Provider Information | |||||||||
NPI: | 1699047563 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VILLALOBOS | ||||||||
FirstName: | GARY | ||||||||
MiddleName: | P | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | IMFT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10852 DES MOINES AVE | ||||||||
Address2: |   | ||||||||
City: | NORTHRIDGE | ||||||||
State: | CA | ||||||||
PostalCode: | 913262662 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8189980024 | ||||||||
FaxNumber: | 8189980024 | ||||||||
Practice Location | |||||||||
Address1: | 921 W AVENUE J | ||||||||
Address2: | SUITE C | ||||||||
City: | LANCASTER | ||||||||
State: | CA | ||||||||
PostalCode: | 935343443 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6619490131 | ||||||||
FaxNumber: | 6617298912 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/07/2012 | ||||||||
LastUpdateDate: | 03/15/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | IMF 62866 | CA | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.