Provider Demographics
NPI:1629649645
Name:VILLEGAS VENEGAS, MARIANA
Entity Type:Individual
Prefix:
First Name:MARIANA
Middle Name:
Last Name:VILLEGAS VENEGAS
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 1:729 REVERE ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-2895
Mailing Address - Country:US
Mailing Address - Phone:734-730-9162
Mailing Address - Fax:
Practice Address - Street 1:35 MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48111-3286
Practice Address - Country:US
Practice Address - Phone:248-333-1408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-09
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician