Provider Demographics
NPI:1881382133
Name:AVILA, MATTHEW (QMHA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:AVILA
Suffix:
Gender:M
Credentials:QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 NE 6TH ST APT 4
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1511
Mailing Address - Country:US
Mailing Address - Phone:541-660-1251
Mailing Address - Fax:
Practice Address - Street 1:707 NE 6TH ST APT 4
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1511
Practice Address - Country:US
Practice Address - Phone:541-660-1251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-25
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty