Provider Demographics
NPI:1780187542
Name:AVILA, JOSE ANGEL JR (LCSW)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:ANGEL
Last Name:AVILA
Suffix:JR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 MAY ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-1519
Mailing Address - Country:US
Mailing Address - Phone:860-792-6999
Mailing Address - Fax:
Practice Address - Street 1:19 MAY ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-1519
Practice Address - Country:US
Practice Address - Phone:860-792-6999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-17
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0112571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical