Healthcare Provider Details

I. General information

NPI: 1457602336
Provider Name (Legal Business Name): ANNIE C VILLANUEVA LSAA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2012
Last Update Date: 10/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 MADEIRA DRIVE SE
ALBUQUERQUE NM
87108-2963
US

IV. Provider business mailing address

123 MADEIRA DRIVE SE
ALBUQUERQUE NM
87108-2963
US

V. Phone/Fax

Practice location:
  • Phone: 505-262-1538
  • Fax: 505-243-5342
Mailing address:
  • Phone: 505-262-1538
  • Fax: 505-243-5342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0065202
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: