Healthcare Provider Details

I. General information

NPI: 1689138638
Provider Name (Legal Business Name): FELICIA AIMI WALLBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2019
Last Update Date: 01/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19824 SW 72ND AVE STE 102
TUALATIN OR
97062-8398
US

IV. Provider business mailing address

13823 NW MILL CREEK DR
PORTLAND OR
97229-5722
US

V. Phone/Fax

Practice location:
  • Phone: 503-773-8600
  • Fax:
Mailing address:
  • Phone: 503-421-1919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberR-5070
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: