Healthcare Provider Details

I. General information

NPI: 1053625475
Provider Name (Legal Business Name): MARK VILLARREAL LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2010
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10535 HOSPITAL WAY RM 122
MATHER CA
95655-4200
US

IV. Provider business mailing address

7218 SERTA CT
ELK GROVE CA
95757-3461
US

V. Phone/Fax

Practice location:
  • Phone: 916-843-2809
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number26031
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: