Basic Information
| Provider Information | |||||||||
| NPI: | 1114081353 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORAN | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3939 NE HANCOCK ST STE 209 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972125321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032908657 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12636 SE STARK ST | ||||||||
| Address2: | PLAZA 125, BLDG J | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972331058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032534600 | ||||||||
| FaxNumber: | 5032534609 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2006 | ||||||||
| LastUpdateDate: | 10/05/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 41146 | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101YP2500X | C3890 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.