Provider Demographics
NPI:1972085967
Name:VILLANUEVA, MICHELLE (CP61057148)
Entity type:Individual
Prefix:MISS
First Name:MICHELLE
Middle Name:
Last Name:VILLANUEVA
Suffix:
Gender:F
Credentials:CP61057148
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 W MISSION AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-2337
Mailing Address - Country:US
Mailing Address - Phone:509-473-4811
Mailing Address - Fax:509-473-4840
Practice Address - Street 1:106 W MISSION AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-2337
Practice Address - Country:US
Practice Address - Phone:509-473-4811
Practice Address - Fax:509-473-4840
Is Sole Proprietor?:No
Enumeration Date:2018-09-05
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60805185101YA0400X
101YM0800X
WACP61057148101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA20097Medicaid