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 1:14344 CAJON AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-4301
Mailing Address - Country:US
Mailing Address - Phone:760-243-3999
Mailing Address - Fax:760-820-2997
Practice Address - Street 1:14344 CAJON AVE STE 102
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-4301
Practice Address - Country:US
Practice Address - Phone:760-243-3999
Practice Address - Fax:760-820-2997
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-16
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13214101YM0800X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty