Provider Demographics
NPI:1275228603
Name:VILLARREAL, CARMEN
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:VILLARREAL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4442 5HT ST W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34207-5621
Mailing Address - Country:US
Mailing Address - Phone:941-744-1211
Mailing Address - Fax:
Practice Address - Street 1:4440 & 4442 5TH ST
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34207
Practice Address - Country:US
Practice Address - Phone:941-744-1211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-11
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
FLRBT-23-268045106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician