Healthcare Provider Details

I. General information

NPI: 1730745662
Provider Name (Legal Business Name): ILCE MARGARITA RODRIGUEZ-AVILA M.S. CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2019
Last Update Date: 08/16/2021
Certification Date: 05/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3209 L ST APT A
SACRAMENTO CA
95816-5251
US

IV. Provider business mailing address

18666 NORTHRIDGE DR
SALINAS CA
93906-1818
US

V. Phone/Fax

Practice location:
  • Phone: 831-585-0152
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number27108
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: