Healthcare Provider Details

I. General information

NPI: 1063652576
Provider Name (Legal Business Name): PRISCILLA AVILA M.A
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2009
Last Update Date: 02/16/2022
Certification Date: 02/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 CABRILLO PARK DR SUITE 300
SANTA ANA CA
92701-5017
US

IV. Provider business mailing address

PO BOX 14094
IRVINE CA
92623-4094
US

V. Phone/Fax

Practice location:
  • Phone: 714-953-4455
  • Fax:
Mailing address:
  • Phone: 949-294-2209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number79768
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: