Provider Demographics
NPI:1336251594
Name:AVILA, MARCIA ILENE (MS MFT)
Entity type:Individual
Prefix:MS
First Name:MARCIA
Middle Name:ILENE
Last Name:AVILA
Suffix:
Gender:F
Credentials:MS MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 EUREKA SQ STE 151
Mailing Address - Street 2:
Mailing Address - City:PACIFICA
Mailing Address - State:CA
Mailing Address - Zip Code:94044-2603
Mailing Address - Country:US
Mailing Address - Phone:650-400-5293
Mailing Address - Fax:650-355-8745
Practice Address - Street 1:80 EUREKA SQ STE 151
Practice Address - Street 2:
Practice Address - City:PACIFICA
Practice Address - State:CA
Practice Address - Zip Code:94044-2603
Practice Address - Country:US
Practice Address - Phone:650-400-5293
Practice Address - Fax:650-355-8745
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC37750106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist