Healthcare Provider Details

I. General information

NPI: 1811630361
Provider Name (Legal Business Name): TIFFANY D WOLLEAT CADCI/CRMII/PSS/QMHA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2022
Last Update Date: 06/30/2025
Certification Date: 06/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 NE 2ND ST
GRESHAM OR
97030-7514
US

IV. Provider business mailing address

211 SE CARUTHERS ST
PORTLAND OR
97214-4502
US

V. Phone/Fax

Practice location:
  • Phone: 971-274-3757
  • Fax: 503-912-5740
Mailing address:
  • Phone: 503-224-1044
  • Fax: 971-260-0355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number25-QMHA-R-6749
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberTHW000106154
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number24-03-11057
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number24-CRM-II-0221
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: