MEDICARE: SUSANA VILLA MC, LPC

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	101YP2500X	Professional Counselor	LPC-14201	AZ

General Provider Information

NPI Number	:	1700279288
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSANA VILLA MC, LPC

Provider Business Mailing Address
First Line	:	4601 E FORT LOWELL RD STE 131
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85712-1183
Country	:	US
Telephone Number	:	520-396-4413
Fax Number	:	520-396-4764

Provider Business Practice Location Address
First Line	:	4601 E FORT LOWELL RD STE 131
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85712-1183
Country	:	US
Telephone Number	:	520-396-4413
Fax Number	:	520-396-4764

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

Provider Enumeration Date	:	03/09/2015
Last Update Date	:	12/10/2024

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