Provider Demographics
NPI:1013484575
Name:AVILLA, JOHANNA
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:
Last Name:AVILLA
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 1:115 S MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:OPELOUSAS
Mailing Address - State:LA
Mailing Address - Zip Code:70570-6133
Mailing Address - Country:US
Mailing Address - Phone:337-407-5060
Mailing Address - Fax:337-407-5104
Practice Address - Street 1:115 S MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-6133
Practice Address - Country:US
Practice Address - Phone:337-407-5060
Practice Address - Fax:337-407-5104
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-01
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
LA2203783831251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251S00000XAgenciesCommunity/Behavioral Health