Provider Demographics
NPI:1609340652
Name:VILLADIEGO, TYRA (LAC)
Entity Type:Individual
Prefix:
First Name:TYRA
Middle Name:
Last Name:VILLADIEGO
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1621 MITHERING LN
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20905-7045
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6935 OAKLAND MILLS RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-4719
Practice Address - Country:US
Practice Address - Phone:410-730-5079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-13
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDUO2465171100000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171100000XOther Service ProvidersAcupuncturist