Provider Demographics
NPI:1023697927
Name:VILLANUEVA, LUIS A
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:A
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 1:10 ALPERT DR
Mailing Address - Street 2:
Mailing Address - City:WAPPINGERS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12590-4602
Mailing Address - Country:US
Mailing Address - Phone:845-390-0010
Mailing Address - Fax:
Practice Address - Street 1:98120 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-4357
Practice Address - Country:US
Practice Address - Phone:774-608-0001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0837841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty