Provider Demographics
NPI:1306140298
Name:LUCCIO, GIZELLA (CADC II & QMHP-C)
Entity type:Individual
Prefix:MS
First Name:GIZELLA
Middle Name:
Last Name:LUCCIO
Suffix:
Gender:F
Credentials:CADC II & QMHP-C
Other - Prefix:
Other - First Name:GABRIELLE
Other - Middle Name:ADELE
Other - Last Name:LESLIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CADC II & QMHP-C
Mailing Address - Street 1:165 TAYLOR AVE.
Mailing Address - Street 2:
Mailing Address - City:TALENT
Mailing Address - State:OR
Mailing Address - Zip Code:97540
Mailing Address - Country:US
Mailing Address - Phone:541-944-0748
Mailing Address - Fax:541-779-3317
Practice Address - Street 1:328 S. CENTRAL AVE, SUITE 212
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501
Practice Address - Country:US
Practice Address - Phone:541-944-0748
Practice Address - Fax:541-482-6462
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-06
Last Update Date:2022-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
OR19-QMNPC-00730101YM0800X
CAM.A.T.S.101YP1600X
OR819261103K00000X
OR12-09-620101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst