Provider Demographics
NPI:1972204352
Name:VILLANUEVA, BRYANT S
Entity type:Individual
Prefix:
First Name:BRYANT
Middle Name:S
Last Name:VILLANUEVA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1914 W SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92407-2303
Mailing Address - Country:US
Mailing Address - Phone:909-582-8248
Mailing Address - Fax:
Practice Address - Street 1:9600 CENTER AVE STE 160
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5838
Practice Address - Country:US
Practice Address - Phone:858-264-5858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician