Provider Demographics
NPI:1114081353
Name:MORAN, GARY S (LPC)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:S
Last Name:MORAN
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3939 NE HANCOCK ST STE 209
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-5321
Mailing Address - Country:US
Mailing Address - Phone:503-290-8657
Mailing Address - Fax:
Practice Address - Street 1:12636 SE STARK ST
Practice Address - Street 2:PLAZA 125, BLDG J
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1058
Practice Address - Country:US
Practice Address - Phone:503-253-4600
Practice Address - Fax:503-253-4609
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41146106H00000X
ORC3890101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR164936Medicaid
OR164936Medicaid