Healthcare Provider Details

I. General information

NPI: 1881965697
Provider Name (Legal Business Name): LUIS EDUARDO DAVILA M.A
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2012
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3831 W VINE ST STE 60
KISSIMMEE FL
34741-4650
US

IV. Provider business mailing address

2950 SAN JUAN CIR APT 322
KISSIMMEE FL
34746-4898
US

V. Phone/Fax

Practice location:
  • Phone: 407-559-4854
  • Fax: 321-332-7799
Mailing address:
  • Phone: 407-653-9370
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number3705
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: