=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154564185
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS WESLEY AYALA LICENSED COUNSELOR
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2009
-----------------------------------------------------
Last Update Date | 12/29/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 880 MAIN ST
-----------------------------------------------------
City | LEBANON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97355
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-258-8210
-----------------------------------------------------
Fax | 541-258-8212
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 280
-----------------------------------------------------
City | LEBANON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97355-0280
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-258-8210
-----------------------------------------------------
Fax | 541-258-8212
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | C1962
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------