Provider Demographics
NPI:1699832113
Name:UTAYDE, MAYNARD VILLAVICENCIO (PT)
Entity Type:Individual
Prefix:MR
First Name:MAYNARD
Middle Name:VILLAVICENCIO
Last Name:UTAYDE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51470 NORWICH DR
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-8426
Mailing Address - Country:US
Mailing Address - Phone:574-257-9880
Mailing Address - Fax:
Practice Address - Street 1:1409 E DAY RD
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3671
Practice Address - Country:US
Practice Address - Phone:574-257-9880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2016-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05005198A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist