MEDICARE: MR. EFRAIN AVILA JR. EDD, LPC, LCPC

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	101Y00000X	Counselor	64717	TX
2	101YP2500X	Professional Counselor	180-004466	IL
3	101YM0800X	Mental Health Counselor	64717	TX
4	101YP2500X	Professional Counselor	180004466	IL
5	101YP2500X	Professional Counselor	64717	TX

General Provider Information

NPI Number	:	1710147921
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. EFRAIN AVILA JR. EDD, LPC, LCPC

Provider Business Mailing Address
First Line	:	P.O. BOX 2203
Second Line	:
City	:	DUBLIN
State	:	CA
Zip	:	94568
Country	:	US
Telephone Number	:	815-985-8924
Fax Number	:	210-924-3557

Provider Business Practice Location Address
First Line	:	94 BRIGGS ST STE 700
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78224-1272
Country	:	US
Telephone Number	:	210-924-3556
Fax Number	:	210-924-3557

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

Provider Enumeration Date	:	06/11/2008
Last Update Date	:	09/30/2015

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