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Individual

SHANE ANTHONY GONZALES

Active
Sole proprietor
Yes

Provider details

NPI number
Gender
Man
Credential
C.R.M.

Contact information

Practice address
1122 NE 122ND AVE STE A200, PORTLAND, OR 97230-2083
(503) 594-4774
Mailing address
1122 NE 122ND AVE STE A200, PORTLAND, OR 97230-2083
(503) 594-4774

Taxonomy

Speciality
Code
Description
License number
State
261QR0405X
Substance Use Disorder Rehabilitation Clinic/Center
Primary
OR

Other

Enumeration date
09/06/2024
Last updated
09/06/2024
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