Healthcare Provider Details

I. General information

NPI: 1164948907
Provider Name (Legal Business Name): KARISSA S VILLARREAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2017
Last Update Date: 08/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 CAMPUS DR N
WATERFORD MI
48328-2754
US

IV. Provider business mailing address

6465 HATCHERY RD
WATERFORD MI
48329-2922
US

V. Phone/Fax

Practice location:
  • Phone: 248-475-6300
  • Fax:
Mailing address:
  • Phone: 248-872-8207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: