Provider Demographics
NPI:1194789545
Name:AVILA, JOSE LUIS (LPC,)
Entity type:Individual
Prefix:MR
First Name:JOSE
Middle Name:LUIS
Last Name:AVILA
Suffix:
Gender:M
Credentials:LPC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4946 SCHUYLER DR
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-5144
Mailing Address - Country:US
Mailing Address - Phone:571-282-3903
Mailing Address - Fax:571-282-3903
Practice Address - Street 1:4946 SCHUYLER DR
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-5144
Practice Address - Country:US
Practice Address - Phone:571-282-3903
Practice Address - Fax:571-282-3903
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701002091101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA83518OtherVALUE OPTIONS
VA31390OtherAETNA
VA7278061OtherAETNA
VA541598045OtherAPS
VA1194789545Medicaid