Healthcare Provider Details

I. General information

NPI: 1669099859
Provider Name (Legal Business Name): LAURA MARIE VILLARREAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2020
Last Update Date: 07/03/2020
Certification Date: 07/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 LOCKHILL SELMA RD STE 106
SAN ANTONIO TX
78213-1552
US

IV. Provider business mailing address

117 OAK KNOB
UNIVERSAL CITY TX
78148-5509
US

V. Phone/Fax

Practice location:
  • Phone: 210-643-1119
  • Fax: 210-910-6881
Mailing address:
  • Phone: 210-993-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-20-121353
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: