=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720512841
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRISHTA SIQUEIROS-VILLALTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2017
-----------------------------------------------------
Last Update Date | 01/03/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 78900 AVENUE 47
-----------------------------------------------------
City | LA QUINTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92253-2070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-777-0881
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 78900 AVENUE 47
-----------------------------------------------------
City | LA QUINTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92253-2070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 1-18-33666
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------