Provider Demographics
NPI:1851764625
Name:GALLISON, DAVE R (LPC)
Entity Type:Individual
Prefix:
First Name:DAVE
Middle Name:R
Last Name:GALLISON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1431 SW WESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-2754
Mailing Address - Country:US
Mailing Address - Phone:503-452-2342
Mailing Address - Fax:
Practice Address - Street 1:1509 SW SUNSET BLVD STE 2G
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-2690
Practice Address - Country:US
Practice Address - Phone:503-704-7796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-02
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC0697101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional