Healthcare Provider Details

I. General information

NPI: 1184345175
Provider Name (Legal Business Name): WILLY ANTHONY DIAZ TAPIA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2022
Last Update Date: 09/28/2022
Certification Date: 09/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E BROADWAY STE 400
EUGENE OR
97401-3104
US

IV. Provider business mailing address

101 E BROADWAY STE 400
EUGENE OR
97401-3104
US

V. Phone/Fax

Practice location:
  • Phone: 541-357-9764
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: