Provider Demographics
NPI:1881965697
Name:DAVILA, LUIS EDUARDO (MA)
Entity type:Individual
Prefix:MR
First Name:LUIS
Middle Name:EDUARDO
Last Name:DAVILA
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2950 SAN JUAN CIR APT 322
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34746-4898
Mailing Address - Country:US
Mailing Address - Phone:407-653-9370
Mailing Address - Fax:
Practice Address - Street 1:3831 W VINE ST STE 60
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4650
Practice Address - Country:US
Practice Address - Phone:407-559-4854
Practice Address - Fax:321-332-7799
Is Sole Proprietor?:No
Enumeration Date:2012-01-25
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
PR3705103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool