Provider Demographics
NPI:1851897177
Name:AVILLA, TRENTON
Entity Type:Individual
Prefix:
First Name:TRENTON
Middle Name:
Last Name:AVILLA
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 1:4701 MT BULLION ST
Mailing Address - Street 2:
Mailing Address - City:DENAIR
Mailing Address - State:CA
Mailing Address - Zip Code:95316-9374
Mailing Address - Country:US
Mailing Address - Phone:209-485-4576
Mailing Address - Fax:
Practice Address - Street 1:632 W 13TH ST
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95341-5908
Practice Address - Country:US
Practice Address - Phone:209-381-6623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-04
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-17-29719103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst