Healthcare Provider Details

I. General information

NPI: 1639520638
Provider Name (Legal Business Name): HAZEL VILLANUEVA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2016
Last Update Date: 06/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16260 VENTURA BLVD STE 600
ENCINO CA
91436-4604
US

IV. Provider business mailing address

6667 WILBUR AVE UNIT 36
RESEDA CA
91335-5170
US

V. Phone/Fax

Practice location:
  • Phone: 818-986-1977
  • Fax:
Mailing address:
  • Phone: 818-648-9106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number9807
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: