Individual
AGUSTINA WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
1132 SW 13TH AVE, PORTLAND, OR 97205-1703
(503) 535-3860
Mailing address
1132 SW 13TH AVE, PORTLAND, OR 97205-1703
Taxonomy
Speciality
Code
Description
License number
State
175T00000X
Peer Specialist
Primary
109318
OR
Other
Enumeration date
01/20/2026
Last updated
01/20/2026
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