Provider Demographics
NPI:1225626914
Name:VILLAVICENCIO, EMILIO (MSOT, OTR/L, CNS)
Entity Type:Individual
Prefix:
First Name:EMILIO
Middle Name:
Last Name:VILLAVICENCIO
Suffix:
Gender:M
Credentials:MSOT, OTR/L, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 ENCLAVE CIR APT 204
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-8271
Mailing Address - Country:US
Mailing Address - Phone:760-791-6763
Mailing Address - Fax:
Practice Address - Street 1:424 ENCLAVE CIR APT 204
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-8271
Practice Address - Country:US
Practice Address - Phone:760-791-6763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-07
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT21609225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist