Provider Demographics
NPI:1376301242
Name:VIERA VILLA, NELSON JORGE
Entity Type:Individual
Prefix:
First Name:NELSON
Middle Name:JORGE
Last Name:VIERA VILLA
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 1:14400 SW 280TH ST APT 102
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-8378
Mailing Address - Country:US
Mailing Address - Phone:786-657-6240
Mailing Address - Fax:
Practice Address - Street 1:14400 SW 280TH ST APT 102
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032-8378
Practice Address - Country:US
Practice Address - Phone:786-657-6240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-06
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB990403106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician