Healthcare Provider Details

I. General information

NPI: 1205050556
Provider Name (Legal Business Name): THERESA DIANNE CABALLERO ORTIZ LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 08/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 NE OAK VIEW DR
VANCOUVER WA
98662-6347
US

IV. Provider business mailing address

10265 SW WALNUT STREET
TIGARD OR
97223-5114
US

V. Phone/Fax

Practice location:
  • Phone: 360-567-2211
  • Fax: 360-567-2212
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW 60541848
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: