Provider Demographics
NPI:1558974469
Name:VILLARREAL MARTINEZ, NICOLE ELVIRA (ASW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ELVIRA
Last Name:VILLARREAL MARTINEZ
Suffix:
Gender:F
Credentials:ASW
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:VILLARREAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5005 TEXAS ST STE 203
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3723
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3845 SPRING DR
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91977-1030
Practice Address - Country:US
Practice Address - Phone:619-906-4528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-29
Last Update Date:2024-10-28
Deactivation Date:2024-10-11
Deactivation Code:
Reactivation Date:2024-10-22
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA1266691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty