Provider Demographics
NPI:1316001290
Name:AVINA, LAURA JO (LCSW)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:JO
Last Name:AVINA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MISS
Other - First Name:LAURA
Other - Middle Name:JO
Other - Last Name:AVINA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:225 MARY LOUISE DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78201-4422
Mailing Address - Country:US
Mailing Address - Phone:210-544-3719
Mailing Address - Fax:
Practice Address - Street 1:4100 E PIEDRAS DR STE 140
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78228-1425
Practice Address - Country:US
Practice Address - Phone:210-544-3719
Practice Address - Fax:210-251-4789
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS18902101YM0800X
TX189021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX101858201Medicaid