Provider Demographics
NPI:1902387517
Name:AVILA, MARIE LOUISE (PT)
Entity Type:Individual
Prefix:MRS
First Name:MARIE
Middle Name:LOUISE
Last Name:AVILA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1544 BASTROP DR
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-6423
Mailing Address - Country:US
Mailing Address - Phone:469-586-7500
Mailing Address - Fax:
Practice Address - Street 1:205 N BONNIE BRAE ST
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201-3766
Practice Address - Country:US
Practice Address - Phone:940-384-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1072288225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist