Provider Demographics
NPI:1700204476
Name:RENOVA-GAXIOLA, SILVIA (LPC)
Entity Type:Individual
Prefix:
First Name:SILVIA
Middle Name:
Last Name:RENOVA-GAXIOLA
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 ADDISON AVE E
Mailing Address - Street 2:SUITE G
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6749
Mailing Address - Country:US
Mailing Address - Phone:208-814-7750
Mailing Address - Fax:208-814-7759
Practice Address - Street 1:2550 ADDISON AVE E
Practice Address - Street 2:SUITE G
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-6749
Practice Address - Country:US
Practice Address - Phone:208-814-7750
Practice Address - Fax:208-814-7759
Is Sole Proprietor?:No
Enumeration Date:2014-03-31
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC5261101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional