Individual
BLAKE WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
CSWA
Contact information
Practice address
3500 NE MARTIN LUTHER KING JR BLVD STE 200, PORTLAND, OR 97212-2093
(503) 327-8205
Mailing address
3500 NE MARTIN LUTHER KING JR BLVD STE 200, PORTLAND, OR 97212-2093
(503) 327-8205
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
24-QMHP-R-2920
OR
1041C0700X
Clinical Social Worker
Primary
A15334
OR
Other
Enumeration date
06/27/2024
Last updated
07/19/2024
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