Provider Demographics
NPI:1508417544
Name:DYTAN, MICHELLE ERIKA VILLAVERT
Entity Type:Individual
Prefix:
First Name:MICHELLE ERIKA
Middle Name:VILLAVERT
Last Name:DYTAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 RIDGEBACK RD STE 21
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-6984
Mailing Address - Country:US
Mailing Address - Phone:619-207-0984
Mailing Address - Fax:
Practice Address - Street 1:1415 RIDGEBACK RD STE 21
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-6984
Practice Address - Country:US
Practice Address - Phone:619-207-0984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-20
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25336225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist