Provider Demographics
NPI:1528628765
Name:AVILA, TYLER RYAN
Entity type:Individual
Prefix:MR
First Name:TYLER
Middle Name:RYAN
Last Name:AVILA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5150 N 6TH ST STE 169
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-7505
Mailing Address - Country:US
Mailing Address - Phone:559-574-5444
Mailing Address - Fax:559-478-5316
Practice Address - Street 1:5150 N 6TH ST STE 169
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-7505
Practice Address - Country:US
Practice Address - Phone:559-574-5444
Practice Address - Fax:559-478-5316
Is Sole Proprietor?:No
Enumeration Date:2019-06-19
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA96324101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health