Provider Demographics
NPI:1558198473
Name:VILLALOBOS, SIMON (LEP4493)
Entity type:Individual
Prefix:
First Name:SIMON
Middle Name:
Last Name:VILLALOBOS
Suffix:
Gender:M
Credentials:LEP4493
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3515 PRESCOTT AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93619-2016
Mailing Address - Country:US
Mailing Address - Phone:559-273-9303
Mailing Address - Fax:
Practice Address - Street 1:3515 PRESCOTT AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93619-2016
Practice Address - Country:US
Practice Address - Phone:559-273-9303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALEP4493103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Single Specialty