Provider Demographics
NPI:1295227676
Name:AVILA, ALYSSA M (MA, ATR)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:M
Last Name:AVILA
Suffix:
Gender:F
Credentials:MA, ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 EASTBROOK RD
Mailing Address - Street 2:
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026-2075
Mailing Address - Country:US
Mailing Address - Phone:781-329-9365
Mailing Address - Fax:781-302-4635
Practice Address - Street 1:20 EASTBROOK RD
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-2075
Practice Address - Country:US
Practice Address - Phone:781-329-9365
Practice Address - Fax:781-302-4635
Is Sole Proprietor?:No
Enumeration Date:2018-06-01
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1992898035Medicaid