Provider Demographics
NPI:1346005071
Name:VILLOCH FERNANDEZ, MARCOS ALEJANDRO
Entity Type:Individual
Prefix:
First Name:MARCOS
Middle Name:ALEJANDRO
Last Name:VILLOCH FERNANDEZ
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 1:159 COLUMBIA DR. POINCIANA.
Mailing Address - Street 2:POLK COUNTY
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34759
Mailing Address - Country:US
Mailing Address - Phone:407-723-2505
Mailing Address - Fax:
Practice Address - Street 1:159 COLUMBIA DR. POINCIANA.
Practice Address - Street 2:POLK COUNTY
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34759
Practice Address - Country:US
Practice Address - Phone:407-723-2505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-21
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-326454106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty