Provider Demographics
NPI:1922496652
Name:AVIGNON, GARY
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:AVIGNON
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 1:4242 WOODCOCK DR
Mailing Address - Street 2:STE 208
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78228-1325
Mailing Address - Country:US
Mailing Address - Phone:210-733-9929
Mailing Address - Fax:210-733-9916
Practice Address - Street 1:4242 WOODCOCK DR
Practice Address - Street 2:STE 208
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78228-1325
Practice Address - Country:US
Practice Address - Phone:210-733-9929
Practice Address - Fax:210-733-9916
Is Sole Proprietor?:No
Enumeration Date:2015-01-05
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10045101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional