Provider Demographics
NPI:1407514425
Name:AVILA, KELLY JO
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:JO
Last Name:AVILA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5558 M 18
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:MI
Mailing Address - Zip Code:48612-8655
Mailing Address - Country:US
Mailing Address - Phone:989-600-3831
Mailing Address - Fax:
Practice Address - Street 1:1234 W CEDAR AVE
Practice Address - Street 2:
Practice Address - City:GLADWIN
Practice Address - State:MI
Practice Address - Zip Code:48624-1818
Practice Address - Country:US
Practice Address - Phone:989-600-3831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-07
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician