Provider Demographics
NPI:1518702976
Name:WALLACE, BLAKE (CSWA)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:CSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 NE MARTIN LUTHER KING JR BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-2093
Mailing Address - Country:US
Mailing Address - Phone:503-327-8205
Mailing Address - Fax:
Practice Address - Street 1:3500 NE MARTIN LUTHER KING JR BLVD STE 200
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-2093
Practice Address - Country:US
Practice Address - Phone:503-327-8205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-27
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24-QMHP-R-29201041C0700X
ORA153341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical