Provider Demographics
NPI:1356625230
Name:VILLAVICENCIO, KELLY SYLVANIA
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:SYLVANIA
Last Name:VILLAVICENCIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 74TH ST
Mailing Address - Street 2:
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047-5609
Mailing Address - Country:US
Mailing Address - Phone:551-556-5218
Mailing Address - Fax:
Practice Address - Street 1:311 74TH ST
Practice Address - Street 2:
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-5609
Practice Address - Country:US
Practice Address - Phone:551-556-5218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-10
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019291235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist