Provider Demographics
NPI:1619571163
Name:VILLAVICENCIO, SOPHIA (QMHS3)
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:
Last Name:VILLAVICENCIO
Suffix:
Gender:F
Credentials:QMHS3
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-0188
Mailing Address - Country:US
Mailing Address - Phone:740-773-4366
Mailing Address - Fax:740-773-4750
Practice Address - Street 1:7976 DAIRY LN
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-9391
Practice Address - Country:US
Practice Address - Phone:740-593-5164
Practice Address - Fax:740-594-6829
Is Sole Proprietor?:No
Enumeration Date:2020-11-25
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst