=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508423138
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ICELLE GRACE VILLANUEVA MARTINEZ PT, DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2019
-----------------------------------------------------
Last Update Date | 05/20/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 36313 ST ANDREWS DR
-----------------------------------------------------
City | LIVONIA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48152-4130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-805-2622
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 36313 ST ANDREWS DR
-----------------------------------------------------
City | LIVONIA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48152-4130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-805-2622
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 5501012216
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------