Provider Demographics
NPI:1669099859
Name:VILLARREAL, LAURA MARIE
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:MARIE
Last Name:VILLARREAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 OAK KNOB
Mailing Address - Street 2:
Mailing Address - City:UNIVERSAL CITY
Mailing Address - State:TX
Mailing Address - Zip Code:78148-5509
Mailing Address - Country:US
Mailing Address - Phone:210-993-4100
Mailing Address - Fax:
Practice Address - Street 1:1850 LOCKHILL SELMA RD STE 106
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78213-1552
Practice Address - Country:US
Practice Address - Phone:210-643-1119
Practice Address - Fax:210-910-6881
Is Sole Proprietor?:No
Enumeration Date:2020-07-03
Last Update Date:2020-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-20-121353106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician