Provider Demographics
NPI:1396003026
Name:VILLARREAL, EDGAR JAVIER (PHD)
Entity Type:Individual
Prefix:DR
First Name:EDGAR
Middle Name:JAVIER
Last Name:VILLARREAL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10021 MILLA CIR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78748-3907
Mailing Address - Country:US
Mailing Address - Phone:956-324-9335
Mailing Address - Fax:
Practice Address - Street 1:7901 METROPOLIS DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78744-3111
Practice Address - Country:US
Practice Address - Phone:512-823-4627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-01
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IA001339103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX390200000XOtherSTUDENT IN AN ORGANIZED HEALTHCARE EDUCATION/TRAINING PROGRAM