Provider Demographics
NPI:1215228150
Name:GWENN CODY, LCSW, PC
Entity Type:Organization
Organization Name:GWENN CODY, LCSW, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GWENN
Authorized Official - Middle Name:
Authorized Official - Last Name:CODY-WALD
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:503-230-0518
Mailing Address - Street 1:819 SE MORRISON ST STE 250
Mailing Address - Street 2:819 SE MORRISON ST STE 250
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-6315
Mailing Address - Country:US
Mailing Address - Phone:503-230-0518
Mailing Address - Fax:503-200-1438
Practice Address - Street 1:819 SE MORRISON ST STE 250
Practice Address - Street 2:819 SE MORRISON ST STE 250
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-6315
Practice Address - Country:US
Practice Address - Phone:503-230-0518
Practice Address - Fax:503-200-1438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-26
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2018261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health