Basic Information
| Provider Information | |||||||||
| NPI: | 1770989840 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLIGAN | ||||||||
| FirstName: | GORDON | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | CADC I | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2318 NE MARTIN LUTHER KING JR BLVD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972123715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033358611 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2318 NE MARTIN LUTHER KING JR BLVD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972123715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033358611 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2014 | ||||||||
| LastUpdateDate: | 07/08/2016 | ||||||||
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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 | 320800000X | 10-03-24 | OR | N | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness | 101YA0400X | 10-03-24 | OR | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 10-03-24 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.