Provider Demographics
NPI:1750642963
Name:VILLAVICENCIO, EDUARDO (MSW)
Entity Type:Individual
Prefix:
First Name:EDUARDO
Middle Name:
Last Name:VILLAVICENCIO
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5338 JOCELYN LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-6184
Mailing Address - Country:US
Mailing Address - Phone:305-600-7569
Mailing Address - Fax:
Practice Address - Street 1:5338 JOCELYN LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-6184
Practice Address - Country:US
Practice Address - Phone:305-600-7569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-04
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0072921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP007292OtherSOCIAL WORKER CERTIFICATION AND LICENSURE BOARD