Provider Demographics
NPI:1902292717
Name:GONZALES, PAMELA LEIGH (MS)
Entity type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:LEIGH
Last Name:GONZALES
Suffix:
Gender:
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5441 S MACADAM AVE STE A
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-6106
Mailing Address - Country:US
Mailing Address - Phone:971-940-0403
Mailing Address - Fax:
Practice Address - Street 1:5441 S MACADAM AVE STE A
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-6106
Practice Address - Country:US
Practice Address - Phone:971-940-0402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-08
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR10772106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA84154OtherMARRIAGE FAMILY THERAPIST INTERN REGISTRATION NUMBER