Healthcare Provider Details

I. General information

NPI: 1376703173
Provider Name (Legal Business Name): SYLVIA AVILA P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2008
Last Update Date: 06/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 N LAKE AVE
PASADENA CA
91104-4521
US

IV. Provider business mailing address

2588 LEEBE AVE
POMONA CA
91768-2742
US

V. Phone/Fax

Practice location:
  • Phone: 626-808-9749
  • Fax:
Mailing address:
  • Phone: 909-282-0655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number34195
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: