Healthcare Provider Details

I. General information

NPI: 1679140198
Provider Name (Legal Business Name): MS. MIA VIANEE VILLARREAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2021
Last Update Date: 08/05/2025
Certification Date: 08/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 W OCEAN BLVD
LOS FRESNOS TX
78566-3635
US

IV. Provider business mailing address

1321 BLUEWING CIR
BROWNSVILLE TX
78520-9267
US

V. Phone/Fax

Practice location:
  • Phone: 956-233-4111
  • Fax:
Mailing address:
  • Phone: 956-312-0391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number124191
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: