Provider Demographics
NPI:1013447622
Name:AVILA-JOHN, KATHLEEN (MT-BC, RBT, QMHS)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:AVILA-JOHN
Suffix:
Gender:F
Credentials:MT-BC, RBT, QMHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2570 TECHNICAL DR
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-6107
Mailing Address - Country:US
Mailing Address - Phone:937-847-8750
Mailing Address - Fax:
Practice Address - Street 1:2570 TECHNICAL DRIVE
Practice Address - Street 2:
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45432
Practice Address - Country:US
Practice Address - Phone:937-847-8750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH106S00000X
OH12091225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0295409Medicaid