Provider Demographics
NPI:1053608570
Name:VILLA, EDGAR ANTONIO (LCSW)
Entity type:Individual
Prefix:
First Name:EDGAR
Middle Name:ANTONIO
Last Name:VILLA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E LA HABRA BLVD
Mailing Address - Street 2:
Mailing Address - City:LA HABRA
Mailing Address - State:CA
Mailing Address - Zip Code:90631-5525
Mailing Address - Country:US
Mailing Address - Phone:714-589-9228
Mailing Address - Fax:
Practice Address - Street 1:400 E. LA HABRA BLVD
Practice Address - Street 2:LA HABRA
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-2640
Practice Address - Country:US
Practice Address - Phone:562-691-3263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-05
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28065101YM0800X
CA610511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health