MEDICARE: MICHAEL WALLER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	L17560	OR

General Provider Information

NPI Number	:	1760360531
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL WALLER

Provider Business Mailing Address
First Line	:	501 N DIXON ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97227-1804
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4110 NE 122ND AVE STE 110
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97230-1359
Country	:	US
Telephone Number	:	503-832-0792
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/21/2025
Last Update Date	:	05/18/2026

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Directions to “ MICHAEL WALLER ” Practice Location

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