Provider Demographics
NPI:1104862077
Name:AVILA, LAURA LEAL (PHD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:LEAL
Last Name:AVILA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 DEVON CT
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-4890
Mailing Address - Country:US
Mailing Address - Phone:815-985-8928
Mailing Address - Fax:
Practice Address - Street 1:9500 TIOGA DR # A
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-3118
Practice Address - Country:US
Practice Address - Phone:210-616-0828
Practice Address - Fax:855-616-0829
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-21
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071006779103TC0700X
TX36945103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1932041OtherBCBS
IL210611Medicare ID - Type Unspecified
IL103496OtherHEALTH ALLIANCE
IL210611Medicare UPIN