Provider Demographics
NPI:1164280772
Name:PALACIOS-AVILA, CARLOS A
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:A
Last Name:PALACIOS-AVILA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:NJ
Mailing Address - Zip Code:07871-1948
Mailing Address - Country:US
Mailing Address - Phone:201-498-9140
Mailing Address - Fax:
Practice Address - Street 1:14 MAIN ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:NJ
Practice Address - Zip Code:07871-1948
Practice Address - Country:US
Practice Address - Phone:201-498-9140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-08
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health