Provider Demographics
NPI:1093041196
Name:AVILA, TINA TANGTHEINKUL (LMFT, BCBA)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:TANGTHEINKUL
Last Name:AVILA
Suffix:
Gender:F
Credentials:LMFT, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 E GUASTI RD STE 100
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-8661
Mailing Address - Country:US
Mailing Address - Phone:909-306-8686
Mailing Address - Fax:909-510-8260
Practice Address - Street 1:3602 INLAND EMPIRE BLVD
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764
Practice Address - Country:US
Practice Address - Phone:909-476-6464
Practice Address - Fax:909-476-6868
Is Sole Proprietor?:No
Enumeration Date:2009-10-23
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51769106H00000X
CA1-15-19368103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist