Provider Demographics
NPI:1750029641
Name:AVILA, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
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 1:4071 MCKENZIE ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-3851
Mailing Address - Country:US
Mailing Address - Phone:951-892-2952
Mailing Address - Fax:
Practice Address - Street 1:22445 ALESSANDRO BLVD # 113-114
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-8358
Practice Address - Country:US
Practice Address - Phone:951-924-9791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-22
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician