Provider Demographics
NPI:1871258012
Name:AVILA, MIKAYLA M (LMT)
Entity Type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:M
Last Name:AVILA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 E SAINT VRAIN ST APT 6
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-4757
Mailing Address - Country:US
Mailing Address - Phone:218-849-0100
Mailing Address - Fax:
Practice Address - Street 1:2121 E SAINT VRAIN ST APT 6
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-4757
Practice Address - Country:US
Practice Address - Phone:218-849-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-02
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0023246225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist