Provider Demographics
NPI:1922332170
Name:VILLAVICENCIO, MARTHA LETTIE (MFTI)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:LETTIE
Last Name:VILLAVICENCIO
Suffix:
Gender:F
Credentials:MFTI
Other - Prefix:
Other - First Name:LETTIE
Other - Middle Name:
Other - Last Name:VILLAVICENCIO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MFT
Mailing Address - Street 1:1150 UNIVERSITY DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-4408
Mailing Address - Country:US
Mailing Address - Phone:650-678-0579
Mailing Address - Fax:
Practice Address - Street 1:1150 UNIVERSITY DR
Practice Address - Street 2:SUITE 110
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-4408
Practice Address - Country:US
Practice Address - Phone:650-678-0579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-21
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50334106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist