Provider Demographics
NPI:1801377742
Name:XAVIER, REGINALD
Entity type:Individual
Prefix:
First Name:REGINALD
Middle Name:
Last Name:XAVIER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 E PIONEER
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-3265
Mailing Address - Country:US
Mailing Address - Phone:253-697-8400
Mailing Address - Fax:253-697-3137
Practice Address - Street 1:5455 ALMIRA DR NE
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98311-8331
Practice Address - Country:US
Practice Address - Phone:360-415-5870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
WACG60894624101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator