Provider Demographics
NPI:1922022946
Name:GAGLIARDO, ANTHONY (LCSW)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:GAGLIARDO
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 HIGH ST SE STE 2048A
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3610
Mailing Address - Country:US
Mailing Address - Phone:503-581-7550
Mailing Address - Fax:971-208-6685
Practice Address - Street 1:161 HIGH ST SE STE 208A
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3660
Practice Address - Country:US
Practice Address - Phone:503-581-7550
Practice Address - Fax:503-581-7550
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL0280101Y00000X, 101YA0400X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR117377Medicare ID - Type Unspecified