Healthcare Provider Details

I. General information

NPI: 1972978633
Provider Name (Legal Business Name): MR. GABRIEL ERIC CICCONE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2015
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5415 SW WESTGATE DR
PORTLAND OR
97221-2409
US

IV. Provider business mailing address

5415 SW WESTGATE DR
PORTLAND OR
97221-2409
US

V. Phone/Fax

Practice location:
  • Phone: 503-645-3581
  • Fax:
Mailing address:
  • Phone: 503-645-3581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: