Provider Demographics
NPI:1861576340
Name:ICARUS COUNSELING INC
Entity type:Organization
Organization Name:ICARUS COUNSELING INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:GAGLIARDO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:503-581-7550
Mailing Address - Street 1:161 HIGH ST SE STE 204
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3610
Mailing Address - Country:US
Mailing Address - Phone:503-581-7550
Mailing Address - Fax:503-581-7550
Practice Address - Street 1:161 HIGH ST SE STE 204
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3610
Practice Address - Country:US
Practice Address - Phone:503-581-7550
Practice Address - Fax:503-581-7550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL0280101YM0800X, 101YA0400X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR117375Medicare ID - Type Unspecified