MEDICARE: AGUSTINA WALLACE

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	175T00000X	Peer Specialist	109318	OR

General Provider Information

NPI Number	:	1811856339
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AGUSTINA WALLACE

Provider Business Mailing Address
First Line	:	1132 SW 13TH AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97205-1703
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1132 SW 13TH AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97205-1703
Country	:	US
Telephone Number	:	503-535-3860
Fax Number	:

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

Provider Enumeration Date	:	01/20/2026
Last Update Date	:	01/20/2026

Similar Medicare Providers

1568401347 — OUTSIDE IN
Practice Location Address:

1132 SW 13TH AVE
PORTLAND, OR
97205-1703

Practice Phone: 503-535-3803
Practice Fax: 503-223-6837

1881700862 — MS. MELINDA M BUTLER RPH
Practice Location Address:

1132 SW 13TH AVE
PORTLAND, OR
97205-1703

Practice Phone: 503-535-3888
Practice Fax: 503-961-8241

1760526313 — DR. MICHELLE L. SALOB ND
Practice Location Address:

1132 SW 13TH AVE
PORTLAND, OR
97205-1703

Practice Phone: 503-522-1818
Practice Fax:

1487772364 — MS. LAURA HELEN BURNETT PSY.N.P.
Practice Location Address:

1132 SW 13TH AVE
PORTLAND, OR
97205-1703

Practice Phone: 971-419-6612
Practice Fax:

1730375858 — MS. HEATHER LOUISE BROWN MA COUNSELING PSYCHO
Practice Location Address:

1132 SW 13TH AVENUE
PORTLAND, OR
97205-1703

Practice Phone: 503-535-3805
Practice Fax: 503-223-6837

1528255460 — MS. MAUREEN CECILIA BRENNAN LCSW
Practice Location Address:

1132 SW 13TH AVENUE
PORTLAND, OR
97205-1703

Practice Phone: 503-535-3845
Practice Fax: 503-223-6837

Directions to “ AGUSTINA WALLACE ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

Copyright © 2007-2026 (Powered by Swiss Vault Engine), all rights reserved. HIPAA liability, trademark, document use and software licensing rules apply. All registered trademarks, used in the content, are the property of their owners. Your interactions with this site are in accordance with our Terms of Use and Privacy Policy.