Provider Demographics
NPI:1083296545
Name:VILLAVICENCIO, DANIEL (PT, DPT)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:VILLAVICENCIO
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 MAMARONECK AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10605-5224
Mailing Address - Country:US
Mailing Address - Phone:888-830-4125
Mailing Address - Fax:
Practice Address - Street 1:1071 INMAN AVE UNIT 4
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-1132
Practice Address - Country:US
Practice Address - Phone:732-518-8868
Practice Address - Fax:732-719-6080
Is Sole Proprietor?:No
Enumeration Date:2021-04-24
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01999100225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist