Provider Demographics
NPI:1063802692
Name:VILLA, GLADYS (LCSW)
Entity type:Individual
Prefix:
First Name:GLADYS
Middle Name:
Last Name:VILLA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31481 UPPER BEAR CREEK RD
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439-7818
Mailing Address - Country:US
Mailing Address - Phone:559-307-1800
Mailing Address - Fax:
Practice Address - Street 1:31481 UPPER BEAR CREEK RD
Practice Address - Street 2:
Practice Address - City:EVERGREEN
Practice Address - State:CO
Practice Address - Zip Code:80439-7818
Practice Address - Country:US
Practice Address - Phone:559-307-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-03
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO099240431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO97720062Medicaid