Provider Demographics
NPI:1154671048
Name:VILLARREAL, CRISTINA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CRISTINA
Middle Name:
Last Name:VILLARREAL
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2802 E GRAND TOUR DR
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-7783
Mailing Address - Country:US
Mailing Address - Phone:208-503-6173
Mailing Address - Fax:
Practice Address - Street 1:2802 E GRAND TOUR DR
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-7783
Practice Address - Country:US
Practice Address - Phone:208-503-6173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-18
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-2231235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist