MEDICARE: MARY CARMEN AVILA GONZALEZ MSW

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	225400000X	Rehabilitation Practitioner	CA
2	1041C0700X	Clinical Social Worker
3	390200000X	Student in an Organized Health Care Education/Training Program	CA

General Provider Information

NPI Number	:	1356187975
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY CARMEN AVILA GONZALEZ MSW

Provider Business Mailing Address
First Line	:	855 3RD AVE STE 1110
Second Line	:
City	:	CHULA VISTA
State	:	CA
Zip	:	91911-1350
Country	:	US
Telephone Number	:	619-934-5770
Fax Number	:

Provider Business Practice Location Address
First Line	:	855 3RD AVE STE 1110
Second Line	:
City	:	CHULA VISTA
State	:	CA
Zip	:	91911-1350
Country	:	US
Telephone Number	:	619-934-5770
Fax Number	:

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

Provider Enumeration Date	:	07/03/2024
Last Update Date	:	03/20/2026

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