Healthcare Provider Details

I. General information

NPI: 1235838996
Provider Name (Legal Business Name): BIANCA A DURAN AVILA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2023
Last Update Date: 02/28/2024
Certification Date: 02/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2865 LOGAN AVE
SAN DIEGO CA
92113-2411
US

IV. Provider business mailing address

4817 PESCADERO AVE
SAN DIEGO CA
92107-3414
US

V. Phone/Fax

Practice location:
  • Phone: 619-232-4357
  • Fax:
Mailing address:
  • Phone: 619-634-5958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: