Provider Demographics
NPI:1881954204
Name:LEE, GUDMUND N (LCSW)
Entity type:Individual
Prefix:MR
First Name:GUDMUND
Middle Name:N
Last Name:LEE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7420 SW GARDEN HOME RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-9599
Mailing Address - Country:US
Mailing Address - Phone:971-337-3500
Mailing Address - Fax:971-337-3636
Practice Address - Street 1:7420 SW GARDEN HOME RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-9599
Practice Address - Country:US
Practice Address - Phone:971-337-3500
Practice Address - Fax:971-337-3636
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-18
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL64941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500683699Medicaid