Provider Demographics
NPI:1588136048
Name:TAVIRA, ALEJANDRO ANTONIO (CG 60475423)
Entity type:Individual
Prefix:
First Name:ALEJANDRO
Middle Name:ANTONIO
Last Name:TAVIRA
Suffix:
Gender:M
Credentials:CG 60475423
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8222 E B ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98404-1031
Mailing Address - Country:US
Mailing Address - Phone:253-720-5739
Mailing Address - Fax:
Practice Address - Street 1:7610 40TH ST W STE 300
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-3834
Practice Address - Country:US
Practice Address - Phone:253-830-6242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-21
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60475423101YM0800X
175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACG60475423Medicaid