Healthcare Provider Details

I. General information

NPI: 1699685644
Provider Name (Legal Business Name): GLORY CHILEEN ENRIQUEZ VILLANUEVA MA, MHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2026
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 E SHORE RD
GREAT NECK NY
11023-2437
US

IV. Provider business mailing address

9234 214TH PL
QUEENS VILLAGE NY
11428-1200
US

V. Phone/Fax

Practice location:
  • Phone: 917-977-0122
  • Fax:
Mailing address:
  • Phone: 917-520-6646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP138548
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: