Provider Demographics
NPI:1881807741
Name:VILLANUEVA, ERICSON G (PT)
Entity type:Individual
Prefix:
First Name:ERICSON
Middle Name:G
Last Name:VILLANUEVA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24901 NORTHWESTERN HWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-2203
Mailing Address - Country:US
Mailing Address - Phone:248-358-3000
Mailing Address - Fax:248-358-3001
Practice Address - Street 1:24901 NORTHWESTERN HWY
Practice Address - Street 2:SUITE 101
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2203
Practice Address - Country:US
Practice Address - Phone:248-358-3000
Practice Address - Fax:248-358-3001
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012802225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist