Healthcare Provider Details

I. General information

NPI: 1154649390
Provider Name (Legal Business Name): DIVINA THEODOSIA VILLANUEVA PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2010
Last Update Date: 05/15/2025
Certification Date: 05/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALIFORNIA MENS COLONY COLONY DR
SAN LUIS OBISPO CA
93409-1953
US

IV. Provider business mailing address

PO BOX 155
MORRO BAY CA
93443-0155
US

V. Phone/Fax

Practice location:
  • Phone: 805-547-7900
  • Fax:
Mailing address:
  • Phone: 775-722-2969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY30361
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: