Provider Demographics
NPI:1205637279
Name:GARCIA AVALOS, SELENE R
Entity type:Individual
Prefix:
First Name:SELENE
Middle Name:R
Last Name:GARCIA AVALOS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7758 S KNOX AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60652-1135
Mailing Address - Country:US
Mailing Address - Phone:708-979-7041
Mailing Address - Fax:
Practice Address - Street 1:332 S MICHIGAN AVE STE 900
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60604-4393
Practice Address - Country:US
Practice Address - Phone:708-979-7041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-24
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-25-421650106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician