=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598074106
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARMEN VILLAVICENCIO LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2010
-----------------------------------------------------
Last Update Date | 11/09/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4610 61ST ST
-----------------------------------------------------
City | WOODSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11377-5766
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-291-1160
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4610 61ST ST
-----------------------------------------------------
City | WOODSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11377-5766
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-291-1160
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 079481
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------