Basic Information
| Provider Information | |||||||||
| NPI: | 1033672613 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEESE | ||||||||
| FirstName: | GABRIELLE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CADC-R | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MEESE | ||||||||
| OtherFirstName: | GABRIELLE | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CADC-R | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 125 SW C ST | ||||||||
| Address2: | |||||||||
| City: | MADRAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977411458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413064566 | ||||||||
| FaxNumber: | 5413209005 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 SW C ST | ||||||||
| Address2: | |||||||||
| City: | MADRAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977411458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413064566 | ||||||||
| FaxNumber: | 5413209005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2019 | ||||||||
| LastUpdateDate: | 04/10/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 82-1905562 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | T-19-184 | 01 | OR | MHACCBO | OTHER |