Provider Demographics
NPI:1881098051
Name:GANCINIA, AUGUSTO (AGENCY AFFILIATED RE)
Entity type:Individual
Prefix:MR
First Name:AUGUSTO
Middle Name:
Last Name:GANCINIA
Suffix:
Gender:M
Credentials:AGENCY AFFILIATED RE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 NE MAPLE
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163
Mailing Address - Country:US
Mailing Address - Phone:509-334-1133
Mailing Address - Fax:509-332-1608
Practice Address - Street 1:340 NE MAPLE
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163
Practice Address - Country:US
Practice Address - Phone:509-334-1133
Practice Address - Fax:509-332-1608
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-17
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAGC60503995101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7104177Medicaid