Provider Demographics
NPI:1518414903
Name:LISIECKI, GINA (LPC)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:LISIECKI
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 1:3251 CHESTER LN S
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:OR
Mailing Address - Zip Code:97352-9755
Mailing Address - Country:US
Mailing Address - Phone:503-385-5683
Mailing Address - Fax:
Practice Address - Street 1:3739 CHERRY AVE NE
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-4849
Practice Address - Country:US
Practice Address - Phone:971-273-8710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-02
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC4232101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health