Provider Demographics
NPI:1619739307
Name:AVILA, DIANA
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
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 1:5705 W 20TH AVE APT 305
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-7539
Mailing Address - Country:US
Mailing Address - Phone:786-867-7696
Mailing Address - Fax:
Practice Address - Street 1:5705 W 20TH AVE APT 305
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-7539
Practice Address - Country:US
Practice Address - Phone:786-867-7696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24-319762106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician