Healthcare Provider Details

I. General information

NPI: 1154813475
Provider Name (Legal Business Name): BRENDA ESMERALDA VILLALOBOS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2018
Last Update Date: 06/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 E CENTER ST
ANAHEIM CA
92805-3457
US

IV. Provider business mailing address

16950 GRAMERCY PL SPC 67A
GARDENA CA
90247-5236
US

V. Phone/Fax

Practice location:
  • Phone: 714-780-0750
  • Fax:
Mailing address:
  • Phone: 310-903-6928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: