Healthcare Provider Details

I. General information

NPI: 1760984082
Provider Name (Legal Business Name): DANIEL GAXIOLA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2018
Last Update Date: 05/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2577 NE COURTNEY DR
BEND OR
97701-7752
US

IV. Provider business mailing address

PO BOX 1432
BEND OR
97709-1432
US

V. Phone/Fax

Practice location:
  • Phone: 541-322-7500
  • Fax: 541-322-7565
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: