Provider Demographics
NPI:1053713354
Name:GAMBETTI, MIRANDA (LPC, CADC II)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:GAMBETTI
Suffix:
Gender:F
Credentials:LPC, CADC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1236 14TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-4529
Mailing Address - Country:US
Mailing Address - Phone:971-267-2217
Mailing Address - Fax:
Practice Address - Street 1:1236 14TH ST
Practice Address - Street 2:
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068-4529
Practice Address - Country:US
Practice Address - Phone:971-267-2217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-18
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13-R-37101YA0400X
ORC3321101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0000WDBCHOtherGROUP MEDICARE
OR164936Medicaid