Provider Demographics
NPI:1750112421
Name:AVILA, STEPHANIE ATHENA (AMFT147286)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ATHENA
Last Name:AVILA
Suffix:
Gender:F
Credentials:AMFT147286
Other - Prefix:MRS
Other - First Name:STEPHANIE
Other - Middle Name:ATHENA
Other - Last Name:AVILA-APPS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1690 W SHAW AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-3519
Mailing Address - Country:US
Mailing Address - Phone:559-250-4461
Mailing Address - Fax:
Practice Address - Street 1:1690 W SHAW AVE STE 201
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-3519
Practice Address - Country:US
Practice Address - Phone:559-250-4461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-13
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT147286106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist