Provider Demographics
NPI:1720782121
Name:GIPSON, AUSTIN
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:
Last Name:GIPSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 NW 14TH AVE APT 211
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2579
Mailing Address - Country:US
Mailing Address - Phone:503-999-1718
Mailing Address - Fax:
Practice Address - Street 1:1550 NW 14TH AVE APT 211
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-2579
Practice Address - Country:US
Practice Address - Phone:503-999-1718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-29
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
ORT-23-3395101YA0400X
ORTHW000109078175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty