Provider Demographics
NPI:1326645375
Name:VILLARREAL LACLEDE, EVELYN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:
Last Name:VILLARREAL LACLEDE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:EVELYN
Other - Middle Name:
Other - Last Name:VILLARREAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2457 GUM BRANCH RD # 600-800
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-4008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2457 GUM BRANCH RD # 600-800
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28540-4008
Practice Address - Country:US
Practice Address - Phone:252-228-4643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-02
Last Update Date:2024-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1337128225100000X
WAPT61393182225100000X
NCCP029624T225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist