Provider Demographics
NPI:1598505133
Name:SEGOVIANO RAMIREZ, GUSTAVO ALFREDO
Entity type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:ALFREDO
Last Name:SEGOVIANO RAMIREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 218
Mailing Address - Street 2:
Mailing Address - City:MARYLHURST
Mailing Address - State:OR
Mailing Address - Zip Code:97036-0218
Mailing Address - Country:US
Mailing Address - Phone:503-266-3050
Mailing Address - Fax:
Practice Address - Street 1:1001 MOLALLA AVE
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-3788
Practice Address - Country:US
Practice Address - Phone:503-722-4110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-30
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker