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General NPI Number Information
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NPI Number | 1962783464
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Entity Type | Individual
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Provider Name | FERNANDO MANUEL AVILA PH.D
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Gender | Male
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Dates
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Enumeration Date | 08/29/2011
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Last Update Date | 01/28/2020
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Provider Practice Location Address
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Address Line | 2671 AVENIR PL
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City | VIENNA
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State | VA
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Zip | 22180-7485
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Country | US
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Telephone | 703-207-8600
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Fax |
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Provider Business Mailing Address
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Address Line | 11125 PELHAM LN
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City | FAIRFAX
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State | VA
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Zip | 22030-4518
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Country | US
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Telephone | 626-203-3242
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | RPS 2012468
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 0810005615
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License Number State | VA
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Taxonomy #3
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY31410
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License Number State | CA
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