Provider Demographics
NPI:1316703770
Name:DAVILA, ELLYMARIE (MS)
Entity type:Individual
Prefix:
First Name:ELLYMARIE
Middle Name:
Last Name:DAVILA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 CALLE GUAYACAN
Mailing Address - Street 2:
Mailing Address - City:CANOVANAS
Mailing Address - State:PR
Mailing Address - Zip Code:00729-9850
Mailing Address - Country:US
Mailing Address - Phone:787-633-3212
Mailing Address - Fax:
Practice Address - Street 1:131 CALLE GUAYACAN
Practice Address - Street 2:
Practice Address - City:CANOVANAS
Practice Address - State:PR
Practice Address - Zip Code:00729-9850
Practice Address - Country:US
Practice Address - Phone:787-633-3212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-23
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR003531103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty