Provider Demographics
NPI:1649629833
Name:VILLANUEVA, MICHEAL
Entity type:Individual
Prefix:
First Name:MICHEAL
Middle Name:
Last Name:VILLANUEVA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:
Other - Last Name:VILLANUEVA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMHC
Mailing Address - Street 1:124 EAST, MIRACLE STRIP PARKWAY
Mailing Address - Street 2:SUITE 602
Mailing Address - City:MARY ESTHER
Mailing Address - State:FL
Mailing Address - Zip Code:32569-1991
Mailing Address - Country:US
Mailing Address - Phone:850-243-7035
Mailing Address - Fax:850-243-8529
Practice Address - Street 1:124 EAST, MIRACLE STRIP PARKWAY
Practice Address - Street 2:SUITE 602
Practice Address - City:MARY ESTHER
Practice Address - State:FL
Practice Address - Zip Code:32569-1991
Practice Address - Country:US
Practice Address - Phone:850-243-7035
Practice Address - Fax:850-243-8529
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-08
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MH14108101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL812734966OtherTAX ID #