Provider Demographics
NPI:1568947828
Name:GORE, TANYA MARIE
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:MARIE
Last Name:GORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5225 JEAN RD APT 511
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-7155
Mailing Address - Country:US
Mailing Address - Phone:503-433-2783
Mailing Address - Fax:
Practice Address - Street 1:1800 BLANKENSHIP RD STE 200
Practice Address - Street 2:
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068-4174
Practice Address - Country:US
Practice Address - Phone:503-433-2783
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-02
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR5235101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health