Provider Demographics
NPI:1689407553
Name:MESA VILLAVICENCIO, MARCOS ULICES
Entity type:Individual
Prefix:MR
First Name:MARCOS
Middle Name:ULICES
Last Name:MESA 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 1:300 NW 114TH AVE APT 105
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33172-4753
Mailing Address - Country:US
Mailing Address - Phone:786-370-0439
Mailing Address - Fax:
Practice Address - Street 1:300 NW 114TH AVE APT 105
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33172-4753
Practice Address - Country:US
Practice Address - Phone:786-370-0439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-24
Last Update Date:2024-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24-3721176106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician