Provider Demographics
NPI:1588719595
Name:REISS, GARY NEAL (LCSW)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:NEAL
Last Name:REISS
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 1:412 W 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-3869
Mailing Address - Country:US
Mailing Address - Phone:541-686-8060
Mailing Address - Fax:541-686-6647
Practice Address - Street 1:412 W 17TH AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3869
Practice Address - Country:US
Practice Address - Phone:541-686-8060
Practice Address - Fax:541-686-6647
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL07461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR0000TLBBHDMedicare ID - Type Unspecified