Provider Demographics
NPI:1639870710
Name:VILLARREAL, KIMBERLY JO (OTR/L)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JO
Last Name:VILLARREAL
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 PALMA VISTA WAY APT 531
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-0939
Mailing Address - Country:US
Mailing Address - Phone:714-310-3658
Mailing Address - Fax:
Practice Address - Street 1:500 PARK AVE
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-3132
Practice Address - Country:US
Practice Address - Phone:904-503-9556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-15
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT23999225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist