Healthcare Provider Details

I. General information

NPI: 1881948545
Provider Name (Legal Business Name): VICTOR VILLARREAL PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2012
Last Update Date: 03/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 UNIVERSITY BLVD 232 STADLER HALL
SAINT LOUIS MO
63121-4400
US

IV. Provider business mailing address

1 UNIVERSITY BLVD 232 STADLER HALL
SAINT LOUIS MO
63121-4400
US

V. Phone/Fax

Practice location:
  • Phone: 315-516-5824
  • Fax: 314-516-5347
Mailing address:
  • Phone: 315-516-5824
  • Fax: 314-516-5347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2012033736
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: