Provider Demographics
NPI:1821443839
Name:BRIZ, LAURA VILLAVICENCIO (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:VILLAVICENCIO
Last Name:BRIZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:D
Other - Last Name:VILLAVICENCIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1627 N FAIRFIELD AVE
Mailing Address - Street 2:3
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-5207
Mailing Address - Country:US
Mailing Address - Phone:813-504-2013
Mailing Address - Fax:
Practice Address - Street 1:150 E HURON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2999
Practice Address - Country:US
Practice Address - Phone:773-572-8383
Practice Address - Fax:312-915-0249
Is Sole Proprietor?:No
Enumeration Date:2016-04-27
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.1528472084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry