Provider Demographics
NPI:1922175215
Name:NANCE, GAEL ANNETTE (LCSW)
Entity Type:Individual
Prefix:
First Name:GAEL
Middle Name:ANNETTE
Last Name:NANCE
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 1:3126 SW RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-6210
Mailing Address - Country:US
Mailing Address - Phone:503-240-1787
Mailing Address - Fax:
Practice Address - Street 1:3126 SW RIDGE DR
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-6210
Practice Address - Country:US
Practice Address - Phone:503-240-1787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR092590Medicaid
OR092590Medicaid