Healthcare Provider Details

I. General information

NPI: 1558974469
Provider Name (Legal Business Name): NICOLE ELVIRA VILLARREAL MARTINEZ ASW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NICOLE VILLARREAL

II. Dates (important events)

Enumeration Date: 08/29/2020
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date: 10/11/2024
Reactivation Date: 10/22/2024

III. Provider practice location address

3845 SPRING DR
SPRING VALLEY CA
91977-1030
US

IV. Provider business mailing address

5005 TEXAS ST STE 203
SAN DIEGO CA
92108-3723
US

V. Phone/Fax

Practice location:
  • Phone: 619-906-4528
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number126669
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: