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General NPI Number Information
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NPI Number | 1245065366
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Entity Type | Individual
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Provider Name | SHANE ANTHONY GONZALES C.R.M.
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Gender | Male
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Dates
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Enumeration Date | 09/06/2024
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Last Update Date | 09/06/2024
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Provider Practice Location Address
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Address Line | 1122 NE 122ND AVE STE A200
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City | PORTLAND
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State | OR
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Zip | 97230-2083
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Country | US
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Telephone | 503-594-4774
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Fax |
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Provider Business Mailing Address
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Address Line | 1122 NE 122ND AVE STE A200
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City | PORTLAND
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State | OR
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Zip | 97230-2083
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Country | US
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Telephone | 503-594-4774
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State | OR
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