Provider Demographics
NPI:1518611730
Name:DAVILA, MARIO JOSE
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:JOSE
Last Name:DAVILA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 MARION ST APT 2
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-6220
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16 MARION ST APT 2
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-6220
Practice Address - Country:US
Practice Address - Phone:787-238-1838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-07
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health