Individual
MRS. JULIANA ELIZABETH WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MSW ACSW, CADC III
Contact information
Practice address
3181 SW SAM JACKSON PARK RD, PORTLAND, OR 97239-3011
(503) 545-9110
Mailing address
10649 NE 13TH AVE, #128, PORTLAND, OR 97211-1557
(503) 545-9110
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
—
—
101YM0800X
Mental Health Counselor
—
—
104100000X
Social Worker
L4458
OR
1041C0700X
Clinical Social Worker
Primary
L4458
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1568401347
—
OR
Enumeration date
09/21/2007
Last updated
03/10/2016
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