Provider Demographics
NPI:1609402924
Name:BUCKBERG, GIA MICHELE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:GIA
Middle Name:MICHELE
Last Name:BUCKBERG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 SW BOUNDARY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-7101
Mailing Address - Country:US
Mailing Address - Phone:503-913-7826
Mailing Address - Fax:
Practice Address - Street 1:1722 NW RALEIGH ST SPC 418
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-1754
Practice Address - Country:US
Practice Address - Phone:503-272-1069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-18
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL68201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical