Provider Demographics
NPI:1215215892
Name:GILBERTSON, TINA (LPC)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:GILBERTSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1235 SE DIVISION ST
Mailing Address - Street 2:SUITE 207
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-1099
Mailing Address - Country:US
Mailing Address - Phone:503-544-6179
Mailing Address - Fax:
Practice Address - Street 1:1235 SE DIVISION ST
Practice Address - Street 2:SUITE 207
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1099
Practice Address - Country:US
Practice Address - Phone:503-544-6179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-29
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC2577101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health