Healthcare Provider Details

I. General information

NPI: 1073697975
Provider Name (Legal Business Name): JULIANN R VILLANUEVA LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 02/03/2020
Certification Date: 02/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 W FIR ST
PORTALES NM
88130-5826
US

IV. Provider business mailing address

122 CREST POINT DR
PORTALES NM
88130-9057
US

V. Phone/Fax

Practice location:
  • Phone: 575-356-5112
  • Fax:
Mailing address:
  • Phone: 505-749-0651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0122481
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: