Healthcare Provider Details

I. General information

NPI: 1043106628
Provider Name (Legal Business Name): MONIQUE AVILES LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3551 ROGER BROOKE DR
FORT SAM HOUSTON TX
78234-4504
US

IV. Provider business mailing address

19179 BLANCO RD STE 105
SAN ANTONIO TX
78258-4009
US

V. Phone/Fax

Practice location:
  • Phone: 210-888-8888
  • Fax:
Mailing address:
  • Phone: 210-580-4814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number089.0136658TELE
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number107507
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: