Provider Demographics
NPI:1538517081
Name:GARCILAZO, AUDRIANA PETRA
Entity Type:Individual
Prefix:
First Name:AUDRIANA
Middle Name:PETRA
Last Name:GARCILAZO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 469
Mailing Address - Street 2:
Mailing Address - City:HEPPNER
Mailing Address - State:OR
Mailing Address - Zip Code:97836-0469
Mailing Address - Country:US
Mailing Address - Phone:541-676-9161
Mailing Address - Fax:
Practice Address - Street 1:120 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HEPPNER
Practice Address - State:OR
Practice Address - Zip Code:97836-2033
Practice Address - Country:US
Practice Address - Phone:541-676-9161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-25
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)