Provider Demographics
NPI:1578922621
Name:MENA, GERARDO (BA, CDC II)
Entity Type:Individual
Prefix:MR
First Name:GERARDO
Middle Name:
Last Name:MENA
Suffix:
Gender:M
Credentials:BA, CDC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18210 E BURNSIDE ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-5343
Mailing Address - Country:US
Mailing Address - Phone:503-766-2582
Mailing Address - Fax:503-465-0165
Practice Address - Street 1:18210 E BURNSIDE ST
Practice Address - Street 2:SUITE A
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-5343
Practice Address - Country:US
Practice Address - Phone:503-766-2582
Practice Address - Fax:503-465-0165
Is Sole Proprietor?:No
Enumeration Date:2016-02-17
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)