Provider Demographics
NPI:1336328897
Name:VILLAVICENCIO, MARIA GENEY (LICENSED MFT)
Entity Type:Individual
Prefix:MRS
First Name:MARIA
Middle Name:GENEY
Last Name:VILLAVICENCIO
Suffix:
Gender:F
Credentials:LICENSED MFT
Other - Prefix:MS
Other - First Name:MARIA
Other - Middle Name:EUGENIA
Other - Last Name:VINCELLO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMFT
Mailing Address - Street 1:380 HAMILTON AVENUE
Mailing Address - Street 2:#511
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94302
Mailing Address - Country:US
Mailing Address - Phone:650-353-7430
Mailing Address - Fax:650-331-3517
Practice Address - Street 1:1218 ELM LAKE CT
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95131-3900
Practice Address - Country:US
Practice Address - Phone:650-353-7430
Practice Address - Fax:650-331-3517
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-31
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51316106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1336328897OtherMEDI-CAL