MEDICARE: MS. BRENDA LEE VILLARREAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist

General Provider Information

NPI Number	:	1407375819
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. BRENDA LEE VILLARREAL

Provider Business Mailing Address
First Line	:	14028 N HWY 183 STE D120
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78717-5992
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3014 W WILLIAM CANNON DR
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78745-5135
Country	:	US
Telephone Number	:	512-250-8800
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/18/2017
Last Update Date	:	09/18/2017

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