Provider Demographics
NPI:1255305306
Name:AVILA, KATHELEEN (MA LIC PSYCHOLOGIS)
Entity Type:Individual
Prefix:
First Name:KATHELEEN
Middle Name:
Last Name:AVILA
Suffix:
Gender:F
Credentials:MA LIC PSYCHOLOGIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3608 44TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-2906
Mailing Address - Country:US
Mailing Address - Phone:612-872-9231
Mailing Address - Fax:612-722-3306
Practice Address - Street 1:3608 44TH AVE S
Practice Address - Street 2:KAVILA@INTEGRATIVEMINDFULNESS.COM
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406-2906
Practice Address - Country:US
Practice Address - Phone:612-872-9231
Practice Address - Fax:612-722-3306
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0449103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN045248300Medicaid