Provider Demographics
NPI:1669904686
Name:MCKINZIE, GIA J (LCSW)
Entity type:Individual
Prefix:
First Name:GIA
Middle Name:J
Last Name:MCKINZIE
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 1:902 SE SPOKANE AVENUE, SUITE 324
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-3837
Mailing Address - Country:US
Mailing Address - Phone:062-307-2604
Mailing Address - Fax:719-301-5267
Practice Address - Street 1:5200 S MACADAM AVE STE 580
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3837
Practice Address - Country:US
Practice Address - Phone:503-231-7854
Practice Address - Fax:503-231-8153
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-29
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
COLSW.0009921186104100000X
ORL10719104100000X
OR101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500774015Medicaid