MEDICARE: KATHELEEN AVILA M.A. LIC PSYCHOLOGIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	LP0449	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255305306
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHELEEN AVILA M.A. LIC PSYCHOLOGIS

Provider Business Mailing Address
First Line	:	3608 44TH AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55406-2906
Country	:	US
Telephone Number	:	612-872-9231
Fax Number	:	612-722-3306

Provider Business Practice Location Address
First Line	:	3608 44TH AVE S
Second Line	:	KAVILA@INTEGRATIVEMINDFULNESS.COM
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55406-2906
Country	:	US
Telephone Number	:	612-872-9231
Fax Number	:	612-722-3306

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/15/2006
Last Update Date	:	08/05/2011

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