Provider Demographics
NPI:1871906859
Name:VILLANUEVA-KHAN, M ROSARIO (MA/MA/LCP)
Entity type:Individual
Prefix:
First Name:M ROSARIO
Middle Name:
Last Name:VILLANUEVA-KHAN
Suffix:
Gender:F
Credentials:MA/MA/LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14489 JOHN HUMPHREY DR
Mailing Address - Street 2:SUITE #202
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-2671
Mailing Address - Country:US
Mailing Address - Phone:312-513-5965
Mailing Address - Fax:708-349-2194
Practice Address - Street 1:14489 JOHN HUMPHREY DR
Practice Address - Street 2:SUITE #202
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-2671
Practice Address - Country:US
Practice Address - Phone:312-513-5965
Practice Address - Fax:708-349-2194
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-06
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.009931101YM0800X
IL180012035101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180012035Medicaid