Provider Demographics
NPI:1386082055
Name:VILLASENOR, RAQUEL YSABEL (LMT, NCBTMB)
Entity type:Individual
Prefix:
First Name:RAQUEL
Middle Name:YSABEL
Last Name:VILLASENOR
Suffix:
Gender:F
Credentials:LMT, NCBTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5630 S HIGHWAY 95
Mailing Address - Street 2:#3B
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:86426-6041
Mailing Address - Country:US
Mailing Address - Phone:480-296-1509
Mailing Address - Fax:
Practice Address - Street 1:5630 S HIGHWAY 95
Practice Address - Street 2:#3B
Practice Address - City:FORT MOHAVE
Practice Address - State:AZ
Practice Address - Zip Code:86426-6041
Practice Address - Country:US
Practice Address - Phone:480-296-1509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-04
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-17744174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist