Provider Demographics
NPI:1720072044
Name:GIFFORD, CHERYL ANNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHERYL
Middle Name:ANNE
Last Name:GIFFORD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SERENITY LN
Mailing Address - Street 2:
Mailing Address - City:COBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97408-9350
Mailing Address - Country:US
Mailing Address - Phone:541-687-1110
Mailing Address - Fax:541-687-9041
Practice Address - Street 1:1 SERENITY LN
Practice Address - Street 2:
Practice Address - City:COBURG
Practice Address - State:OR
Practice Address - Zip Code:97408-9350
Practice Address - Country:US
Practice Address - Phone:541-687-1110
Practice Address - Fax:541-687-9041
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1309103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR181430Medicaid
OR825411000OtherREGENCE BCBS PROV. #
ORJ6460 01OtherPACIFICSOURCE INS. PROV.
ORJ6460 01OtherPACIFICSOURCE INS. PROV.