Provider Demographics
NPI:1336853555
Name:GALLARDO, AXEL DANIE (SUDPT)
Entity Type:Individual
Prefix:
First Name:AXEL
Middle Name:DANIE
Last Name:GALLARDO
Suffix:
Gender:M
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 23RD AVE S
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98144-2309
Mailing Address - Country:US
Mailing Address - Phone:206-709-1777
Mailing Address - Fax:
Practice Address - Street 1:113 23RD AVE S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98144-2309
Practice Address - Country:US
Practice Address - Phone:206-709-1777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-11
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61360511101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)