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 1:142 EL MONTE ST
Mailing Address - Street 2:
Mailing Address - City:UMATILLA
Mailing Address - State:OR
Mailing Address - Zip Code:97882-9644
Mailing Address - Country:US
Mailing Address - Phone:541-862-4570
Mailing Address - Fax:360-844-5184
Practice Address - Street 1:256 E HURLBURT AVE STE 115
Practice Address - Street 2:
Practice Address - City:HERMISTON
Practice Address - State:OR
Practice Address - Zip Code:97838-2443
Practice Address - Country:US
Practice Address - Phone:541-862-4570
Practice Address - Fax:360-844-5184
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-25
Last Update Date:2025-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YM0800X
ORC5495101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health