Provider Demographics
NPI:1790567915
Name:VILLAZON, ROBERTO ANDRES
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:ANDRES
Last Name:VILLAZON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 TALL CEDAR CT
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20876-6053
Mailing Address - Country:US
Mailing Address - Phone:240-780-1316
Mailing Address - Fax:
Practice Address - Street 1:1517 REISTERSTOWN RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21208-4325
Practice Address - Country:US
Practice Address - Phone:410-541-1316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-23
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDRBT-24-325240106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician