Provider Demographics
NPI:1144967266
Name:VILLA, MAYLINE (LCDA)
Entity type:Individual
Prefix:MRS
First Name:MAYLINE
Middle Name:
Last Name:VILLA
Suffix:
Gender:F
Credentials:LCDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1380
Mailing Address - Street 2:
Mailing Address - City:BOQUERON
Mailing Address - State:PR
Mailing Address - Zip Code:00622-1380
Mailing Address - Country:US
Mailing Address - Phone:787-409-7372
Mailing Address - Fax:
Practice Address - Street 1:URB. EXT. ALTURAS DE JOYUDA
Practice Address - Street 2:CALLE ANA GABRIELA FF2
Practice Address - City:CABO ROJO
Practice Address - State:PR
Practice Address - Zip Code:00623
Practice Address - Country:US
Practice Address - Phone:787-409-7372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-19
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR7298103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty