=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154649390
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIVINA THEODOSIA VILLANUEVA PSYD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2010
-----------------------------------------------------
Last Update Date | 05/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CALIFORNIA MENS COLONY COLONY DR
-----------------------------------------------------
City | SAN LUIS OBISPO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93409-1953
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-547-7900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 155
-----------------------------------------------------
City | MORRO BAY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93443-0155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-722-2969
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY30361
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------