| Doctor Name: | MICHEAL VILLANUEVA |
| NPI Number: | 1649629833 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | |
| License Number: | 812734966 |
| Business Practice Address: | 124 East, Miracle Strip Parkway Suite 602 Mary Esther, FL - 325691991 |
| Business Phone Number: | 8502437035 |
| Business Fax Number: | 8502438529 |
| Mailing Address: | 124 East, Miracle Strip Parkway, Suite 602 MARY ESTHER |
| State: | FL |
| Postal Code: | 325691991 |
| Phone Number: | 8502437035 |
| Fax Number: | 8502438529 |
| NPI Enumeration Date: | 06/08/2016 |
| NPI Last Update Date: | 06/08/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YM0800X |
| License Number: | 812734966 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | FL |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Mental Health |
| Taxonomy Definition: | |