Provider Demographics
NPI:1699257147
Name:VILLARREAL, AMY JEAN (BA, SLP-ASSISTANT)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:JEAN
Last Name:VILLARREAL
Suffix:
Gender:F
Credentials:BA, SLP-ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9826 MARBACH CYN
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78245-1695
Mailing Address - Country:US
Mailing Address - Phone:210-289-6129
Mailing Address - Fax:
Practice Address - Street 1:4211 GARDENDALE ST STE A201
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3180
Practice Address - Country:US
Practice Address - Phone:210-614-4434
Practice Address - Fax:210-614-4407
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-31
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1578708483Medicaid