MEDICARE: JOSE AVILA MA

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	106H00000X	Marriage & Family Therapist	166.000703	IL

General Provider Information

NPI Number	:	1740847268
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSE AVILA MA

Provider Business Mailing Address
First Line	:	3047 W CERMAK RD FL 3
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60623-3421
Country	:	US
Telephone Number	:	773-522-7798
Fax Number	:

Provider Business Practice Location Address
First Line	:	3047 W CERMAK RD FL 3
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60623-3421
Country	:	US
Telephone Number	:	773-522-7798
Fax Number	:

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

Provider Enumeration Date	:	05/20/2019
Last Update Date	:	05/20/2019

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