Provider Demographics
NPI:1245065366
Name:GONZALES, SHANE ANTHONY (CRM)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:ANTHONY
Last Name:GONZALES
Suffix:
Gender:M
Credentials:CRM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1122 NE 122ND AVE STE A200
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-2083
Mailing Address - Country:US
Mailing Address - Phone:503-594-4774
Mailing Address - Fax:
Practice Address - Street 1:1122 NE 122ND AVE STE A200
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-2083
Practice Address - Country:US
Practice Address - Phone:503-594-4774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-06
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder