Healthcare Provider Details

I. General information

NPI: 1033630363
Provider Name (Legal Business Name): RYELY WILPONE MSW, LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2017
Last Update Date: 11/28/2023
Certification Date: 11/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 NE 8TH ST
GRESHAM OR
97030-7317
US

IV. Provider business mailing address

619 SW 6TH AVE. 5TH FL
PORTLAND OR
97209-8459
US

V. Phone/Fax

Practice location:
  • Phone: 503-988-5155
  • Fax: 503-988-5185
Mailing address:
  • Phone: 503-988-7468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL7672
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier022959
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: