Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 106S00000X | Behavior Technician |
NPI | 1003386442 |
---|---|
Provider Name | Krystal Madeline Avila |
First Address | Modesto, CA 95355-1582 |
Second Address | Stockton, CA 95219-5435 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/11/2018 |
Last Update Date | 28/11/2018 |