Provider Demographics
NPI:1942471412
Name:AVILES, JERONIMO BOLIVAR (LPC)
Entity Type:Individual
Prefix:MR
First Name:JERONIMO
Middle Name:BOLIVAR
Last Name:AVILES
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4755 NORTH FWY
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76106-2315
Mailing Address - Country:US
Mailing Address - Phone:817-881-5883
Mailing Address - Fax:817-358-0323
Practice Address - Street 1:3800 VICTORIA CT
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-6159
Practice Address - Country:US
Practice Address - Phone:817-881-5883
Practice Address - Fax:817-624-7425
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-12
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX59034101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional