Provider Demographics
NPI:1659901908
Name:VILLARREAL, LUIS (MT-BC)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:
Last Name:VILLARREAL
Suffix:
Gender:M
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9128 LAKE CHARLES DR
Mailing Address - Street 2:
Mailing Address - City:LOS FRESNOS
Mailing Address - State:TX
Mailing Address - Zip Code:78566-4706
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6000 DANUBIO STE C
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78526-8439
Practice Address - Country:US
Practice Address - Phone:956-372-2932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-24
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15229225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX842641655Medicaid