Provider Demographics
NPI:1942703707
Name:AVILES, MARY L
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:AVILES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6474 VINELAND RD UNIT 207
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-7879
Mailing Address - Country:US
Mailing Address - Phone:787-346-6888
Mailing Address - Fax:
Practice Address - Street 1:6474 VINELAND RD UNIT 207
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-7879
Practice Address - Country:US
Practice Address - Phone:787-346-6888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-16
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL09202103Medicaid