Basic Information
| Provider Information | |||||||||
| NPI: | 1861809428 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CALVILLO | ||||||||
| FirstName: | MICHAIL | ||||||||
| MiddleName: | GERARDO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2013 MICCOSUKEE ROAD | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8666100580 | ||||||||
| FaxNumber: | 8666100580 | ||||||||
| Practice Location | |||||||||
| Address1: | 6224 NW 43RD ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3528355520 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2014 | ||||||||
| LastUpdateDate: | 07/16/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.