Provider Demographics
NPI:1053968636
Name:VILLEGAS, MARY ROSE
Entity type:Individual
Prefix:
First Name:MARY ROSE
Middle Name:
Last Name:VILLEGAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:576 BROADHOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-5002
Mailing Address - Country:US
Mailing Address - Phone:631-659-5859
Mailing Address - Fax:
Practice Address - Street 1:5 JAMES ST
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:NJ
Practice Address - Zip Code:07644-2305
Practice Address - Country:US
Practice Address - Phone:631-359-5859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-20
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant