Provider Demographics
NPI:1689132375
Name:VILLA PEDIATRIC THERAPY LLC
Entity Type:Organization
Organization Name:VILLA PEDIATRIC THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLARREAL
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:208-503-6173
Mailing Address - Street 1:PO BOX 793
Mailing Address - Street 2:
Mailing Address - City:RATHDRUM
Mailing Address - State:ID
Mailing Address - Zip Code:83858-0793
Mailing Address - Country:US
Mailing Address - Phone:208-503-6173
Mailing Address - Fax:208-712-6808
Practice Address - Street 1:8052 W MAIN ST UNIT 107
Practice Address - Street 2:
Practice Address - City:RATHDRUM
Practice Address - State:ID
Practice Address - Zip Code:83858-4915
Practice Address - Country:US
Practice Address - Phone:208-503-6173
Practice Address - Fax:208-712-6808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-12
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty