Provider Demographics
NPI:1265115224
Name:VILLANUEVA, MARK THOMAS
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:THOMAS
Last Name:VILLANUEVA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 752123
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77275-2123
Mailing Address - Country:US
Mailing Address - Phone:312-476-9064
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 861684
Practice Address - Street 2:
Practice Address - City:WAHIAWA
Practice Address - State:HI
Practice Address - Zip Code:96786-8563
Practice Address - Country:US
Practice Address - Phone:808-220-7042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-08
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI2523104100000X
HI52911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker