Provider Demographics
NPI:1760823215
Name:VILLANUEVA-BLACK, MARY GRACE (OTR/L)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:GRACE
Last Name:VILLANUEVA-BLACK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4015 CHEEK ROAD
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-4905
Mailing Address - Country:US
Mailing Address - Phone:919-428-0931
Mailing Address - Fax:
Practice Address - Street 1:4015 CHEEK ROAD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-4905
Practice Address - Country:US
Practice Address - Phone:919-428-0931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-12
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5889225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist