=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497155725
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AXIS THERAPIES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2014
-----------------------------------------------------
Last Update Date | 08/22/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6370 CHESTERFIELD LN
-----------------------------------------------------
City | RENO
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89523-2713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-813-7489
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6370 CHESTERFIELD LN
-----------------------------------------------------
City | RENO
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89523-2713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-813-7489
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. ANTHONY RAY DIQUARTO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 775-813-7489
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------