Basic Information
| Provider Information | |||||||||
| NPI: | 1790160794 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VILLALTA | ||||||||
| FirstName: | KEVIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 93606 | ||||||||
| Address2: | |||||||||
| City: | CITY OF INDUSTRY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917153606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8185773892 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11721 TELEGRAPH RD | ||||||||
| Address2: | |||||||||
| City: | SANTA FE SPRINGS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906703674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5629498455 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2015 | ||||||||
| LastUpdateDate: | 06/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | ASW71678 | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101YM0800X | ASW107795 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.