Healthcare Provider Details

I. General information

NPI: 1053608570
Provider Name (Legal Business Name): EDGAR ANTONIO VILLA LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2011
Last Update Date: 12/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E. LA HABRA BLVD LA HABRA
CERRITOS CA
90703-2640
US

IV. Provider business mailing address

400 E LA HABRA BLVD
LA HABRA CA
90631-5525
US

V. Phone/Fax

Practice location:
  • Phone: 562-691-3263
  • Fax:
Mailing address:
  • Phone: 714-589-9228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number28065
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number61051
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: