MEDICARE: MANUEL VILLAGRANA ACT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TA0400X	Addiction (Substance Use Disorder) Psychologist	8712	SD

General Provider Information

NPI Number	:	1336092873
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MANUEL VILLAGRANA ACT

Provider Business Mailing Address
First Line	:	1520 HAINES AVE STE 6
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57701-0710
Country	:	US
Telephone Number	:	605-716-7841
Fax Number	:	605-718-0404

Provider Business Practice Location Address
First Line	:	112 N CHICAGO ST
Second Line	:
City	:	HOT SPRINGS
State	:	SD
Zip	:	57747-1632
Country	:	US
Telephone Number	:	605-745-6300
Fax Number	:	605-718-0404

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/16/2026
Last Update Date	:	02/16/2026

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Directions to “ MANUEL VILLAGRANA ACT” Practice Location

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