Healthcare Provider Details

I. General information

NPI: 1104240746
Provider Name (Legal Business Name): EILEEN MARIE AVILA PSICOLOGA CLINICA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2014
Last Update Date: 02/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

COND MARINA I CALLE ASISCLO SOLER APT.3703
BARCELOENTA PR
00617
US

IV. Provider business mailing address

COND MARINA I APT. 3703
BARCELONETA PR
00617-2897
US

V. Phone/Fax

Practice location:
  • Phone: 939-644-4430
  • Fax:
Mailing address:
  • Phone: 939-644-4430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number005385
License Number StatePR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: