Healthcare Provider Details

I. General information

NPI: 1568597722
Provider Name (Legal Business Name): MARTHA ANGELICA AVILA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 09/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 E FOOTHILL BLVD
PASADENA CA
91107-3406
US

IV. Provider business mailing address

PO BOX 2451
PASADENA CA
91102-2451
US

V. Phone/Fax

Practice location:
  • Phone: 626-744-5230
  • Fax: 626-744-5230
Mailing address:
  • Phone: 626-893-0191
  • Fax: 626-893-0191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: