Provider Demographics
NPI:1003244740
Name:GATES, MARY LISA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:LISA
Last Name:GATES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 N VANCOUVER AVE
Mailing Address - Street 2:SUITE 230
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1630
Mailing Address - Country:US
Mailing Address - Phone:503-413-5161
Mailing Address - Fax:503-413-4898
Practice Address - Street 1:2800 N VANCOUVER AVE
Practice Address - Street 2:SUITE 230
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1630
Practice Address - Country:US
Practice Address - Phone:503-413-5161
Practice Address - Fax:503-413-4898
Is Sole Proprietor?:No
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL34611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical