Provider Demographics
NPI:1992844203
Name:GILLES, TIM C (CADC 1)
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:C
Last Name:GILLES
Suffix:
Gender:M
Credentials:CADC 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2142 SE 52ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-3908
Mailing Address - Country:US
Mailing Address - Phone:503-535-1150
Mailing Address - Fax:503-535-1192
Practice Address - Street 1:1312 SW WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2327
Practice Address - Country:US
Practice Address - Phone:503-535-1150
Practice Address - Fax:503-535-1192
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)