Provider Demographics
NPI:1962783464
Name:AVILA, FERNANDO MANUEL (PHD)
Entity type:Individual
Prefix:
First Name:FERNANDO
Middle Name:MANUEL
Last Name:AVILA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11125 PELHAM LN
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-4518
Mailing Address - Country:US
Mailing Address - Phone:626-203-3242
Mailing Address - Fax:
Practice Address - Street 1:2671 AVENIR PL
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-7485
Practice Address - Country:US
Practice Address - Phone:703-207-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-29
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPS 2012468103TC0700X
VA0810005615103TC0700X
CAPSY31410103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical