Provider Demographics
NPI:1942787924
Name:AVILA, ALEXANDRIA MAXINE
Entity Type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:MAXINE
Last Name:AVILA
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 1:1075 ALBERT DR SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-1805
Mailing Address - Country:US
Mailing Address - Phone:503-984-0858
Mailing Address - Fax:
Practice Address - Street 1:1075 ALBERT DR SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-1805
Practice Address - Country:US
Practice Address - Phone:503-984-0858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-23
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst