Healthcare Provider Details

I. General information

NPI: 1639832116
Provider Name (Legal Business Name): GUSTAVO ESTRADA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2021
Last Update Date: 10/20/2021
Certification Date: 10/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

246 N MISSION ST
WENATCHEE WA
98801-2004
US

IV. Provider business mailing address

1229 MAPLE ST
WENATCHEE WA
98801-1419
US

V. Phone/Fax

Practice location:
  • Phone: 509-293-8116
  • Fax:
Mailing address:
  • Phone: 509-393-8158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberWDL2BS4G013B
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberWDL2BS4G013B
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: