Provider Demographics
NPI:1043778251
Name:AVILA, CRISTINA
Entity type:Individual
Prefix:
First Name:CRISTINA
Middle Name:
Last Name:AVILA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11201 BENTON ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92357-1000
Mailing Address - Country:US
Mailing Address - Phone:909-825-7084
Mailing Address - Fax:
Practice Address - Street 1:72700 DINAH SHORE DR
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92211-0818
Practice Address - Country:US
Practice Address - Phone:800-741-8387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-06
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA111817106H00000X
CA140989106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7184OtherMEDI-CAL
CA7708OtherMEDI-CAL
CA7368OtherMEDI-CAL
CA7667OtherMEDI-CAL