Provider Demographics
NPI:1750916086
Name:GORE, OZARK
Entity type:Individual
Prefix:
First Name:OZARK
Middle Name:
Last Name:GORE
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 1:6703 OAKBROOK CT SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98513-5672
Mailing Address - Country:US
Mailing Address - Phone:808-214-4948
Mailing Address - Fax:
Practice Address - Street 1:4804 LACEY BLVD SE STE A
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-5733
Practice Address - Country:US
Practice Address - Phone:360-799-5782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-06
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)