Provider Demographics
NPI:1710572250
Name:VILLAVICENCIO, MARTHA AMELIA
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:AMELIA
Last Name:VILLAVICENCIO
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 1:7371 NW 169TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-4121
Mailing Address - Country:US
Mailing Address - Phone:786-316-8808
Mailing Address - Fax:
Practice Address - Street 1:7371 NW 169TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-4121
Practice Address - Country:US
Practice Address - Phone:786-316-8808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-06
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-509580106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRBT-509580Medicaid