Healthcare Provider Details

I. General information

NPI: 1114529591
Provider Name (Legal Business Name): XIANGYA GAO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2020
Last Update Date: 11/11/2020
Certification Date: 11/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 SILVER STONE DR
TEMPLE TX
76502-3552
US

IV. Provider business mailing address

604 SILVER STONE DR
TEMPLE TX
76502-3552
US

V. Phone/Fax

Practice location:
  • Phone: 254-780-5358
  • Fax:
Mailing address:
  • Phone: 254-780-5358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number75083
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: