Provider Demographics
NPI:1699096206
Name:WILLOUGHBY, GRACIELA R (ADTS3)
Entity type:Individual
Prefix:
First Name:GRACIELA
Middle Name:R
Last Name:WILLOUGHBY
Suffix:
Gender:F
Credentials:ADTS3
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 MAPLE CT
Mailing Address - Street 2:
Mailing Address - City:FILLMORE
Mailing Address - State:CA
Mailing Address - Zip Code:93015-1039
Mailing Address - Country:US
Mailing Address - Phone:805-200-7234
Mailing Address - Fax:
Practice Address - Street 1:828 W VENTURA ST
Practice Address - Street 2:
Practice Address - City:FILLMORE
Practice Address - State:CA
Practice Address - Zip Code:93015-1876
Practice Address - Country:US
Practice Address - Phone:805-520-9639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-17
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA174400000XOtherOTHER