Provider Demographics
NPI:1548999105
Name:VILLANUEVA, MARIA DE JESUS (BEHAVIORAL THERAPIST)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:DE JESUS
Last Name:VILLANUEVA
Suffix:
Gender:F
Credentials:BEHAVIORAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 CONCAR DR STE 4-134
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-2681
Mailing Address - Country:US
Mailing Address - Phone:650-931-6300
Mailing Address - Fax:
Practice Address - Street 1:400 CONCAR DR STE 4-134
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-2681
Practice Address - Country:US
Practice Address - Phone:650-931-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-08
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11939817103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0Medicaid