Provider Demographics
NPI:1699168096
Name:VILLAVICENCIO, LAURA CRISTINA (DPT)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:CRISTINA
Last Name:VILLAVICENCIO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 LUDLAM DR
Mailing Address - Street 2:
Mailing Address - City:MIAMI SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33166-4957
Mailing Address - Country:US
Mailing Address - Phone:305-884-4308
Mailing Address - Fax:
Practice Address - Street 1:1500 S DOUGLAS RD
Practice Address - Street 2:SUITE 210
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-4108
Practice Address - Country:US
Practice Address - Phone:305-448-0146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-09
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL30083225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist