Provider Demographics
NPI:1720414345
Name:VILLARREAL, LUIS
Entity Type:Individual
Prefix:MR
First Name:LUIS
Middle Name:
Last Name:VILLARREAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4164 BROCKTON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-3400
Mailing Address - Country:US
Mailing Address - Phone:951-683-5193
Mailing Address - Fax:951-683-6019
Practice Address - Street 1:4164 BROCKTON AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-3400
Practice Address - Country:US
Practice Address - Phone:951-683-5193
Practice Address - Fax:951-683-6019
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-16
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAPCC13214101YP2500X
CA13214101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty