Provider Demographics
NPI:1255781613
Name:GAMEZ, SERGIO
Entity type:Individual
Prefix:
First Name:SERGIO
Middle Name:
Last Name:GAMEZ
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 1:404 NW 23RD ST
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-5539
Mailing Address - Country:US
Mailing Address - Phone:541-753-7801
Mailing Address - Fax:541-753-7805
Practice Address - Street 1:404 NW 23RD ST
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-5539
Practice Address - Country:US
Practice Address - Phone:541-753-7801
Practice Address - Fax:541-753-7805
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-16
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1952441271103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst