Healthcare Provider Details

I. General information

NPI: 1700131596
Provider Name (Legal Business Name): VIVIAN ANN VILLALOBOS MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2012
Last Update Date: 11/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5051 CANYON CREST DR STE 204
RIVERSIDE CA
92507-6035
US

IV. Provider business mailing address

5051 CANYON CREST DR STE 204
RIVERSIDE CA
92507-6035
US

V. Phone/Fax

Practice location:
  • Phone: 951-682-1488
  • Fax: 951-682-1485
Mailing address:
  • Phone: 951-682-1488
  • Fax: 951-682-1485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number107822
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: