Provider Demographics
NPI:1861212516
Name:GUTIERREZ VILLAVICENCIO, MANUEL A
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:A
Last Name:GUTIERREZ VILLAVICENCIO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9259 SW 227TH ST UNIT 2
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33190-1909
Mailing Address - Country:US
Mailing Address - Phone:786-385-9220
Mailing Address - Fax:
Practice Address - Street 1:9259 SW 227TH ST UNIT 2
Practice Address - Street 2:
Practice Address - City:CUTLER BAY
Practice Address - State:FL
Practice Address - Zip Code:33190-1909
Practice Address - Country:US
Practice Address - Phone:786-385-9220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-16
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-379452106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty