Provider Demographics
NPI:1407938145
Name:VILLARREAL, TIMOTHY D (LMP)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:D
Last Name:VILLARREAL
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8828 BROAD ST NE
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-3508
Mailing Address - Country:US
Mailing Address - Phone:509-764-2119
Mailing Address - Fax:
Practice Address - Street 1:830 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-5932
Practice Address - Country:US
Practice Address - Phone:509-765-9205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00021183225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist