Healthcare Provider Details

I. General information

NPI: 1003743915
Provider Name (Legal Business Name): ANDREA MARIE AVILA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 AVENIDA TALEGA
SAN CLEMENTE CA
92673-6710
US

IV. Provider business mailing address

1130 AVENIDA TALEGA
SAN CLEMENTE CA
92673-6710
US

V. Phone/Fax

Practice location:
  • Phone: 949-234-5955
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number260010103
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: