Provider Demographics
NPI:1174020622
Name:SICILIANO AVILA, CONNIE M (PHD)
Entity Type:Individual
Prefix:DR
First Name:CONNIE
Middle Name:M
Last Name:SICILIANO 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:PO BOX 863842
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75086-3842
Mailing Address - Country:US
Mailing Address - Phone:214-830-9879
Mailing Address - Fax:
Practice Address - Street 1:735 JUSTIN RD
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-4840
Practice Address - Country:US
Practice Address - Phone:214-830-9879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-11
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37241103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling