Provider Demographics
NPI:1164566212
Name:WELCH, GWEN (LICSW)
Entity Type:Individual
Prefix:MS
First Name:GWEN
Middle Name:
Last Name:WELCH
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:MS
Other - First Name:GWEN
Other - Middle Name:
Other - Last Name:SLAFF-WELCH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICSW
Mailing Address - Street 1:604 CHARMAN ST
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-3018
Mailing Address - Country:US
Mailing Address - Phone:503-877-8218
Mailing Address - Fax:503-389-7945
Practice Address - Street 1:604 CHARMAN ST
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-3018
Practice Address - Country:US
Practice Address - Phone:503-877-8218
Practice Address - Fax:503-389-7945
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL41781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP07539OtherBLUE CROSS BLUE SHIELD
OR50069742Medicaid