Provider Demographics
NPI:1124486774
Name:SPATH, GORDON (CRM, PSS,ORO)
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:
Last Name:SPATH
Suffix:
Gender:M
Credentials:CRM, PSS,ORO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5030 BROADWAY ST APT 14
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-3365
Mailing Address - Country:US
Mailing Address - Phone:503-317-0572
Mailing Address - Fax:
Practice Address - Street 1:5030 BROADWAY ST APT 14
Practice Address - Street 2:
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068-3365
Practice Address - Country:US
Practice Address - Phone:503-317-0572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-10
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15-CRM-063101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)