Provider Demographics
NPI:1033630363
Name:WILPONE, RYELY (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:RYELY
Middle Name:
Last Name:WILPONE
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 SW 6TH AVE.
Mailing Address - Street 2:5TH FL
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-8459
Mailing Address - Country:US
Mailing Address - Phone:503-988-7468
Mailing Address - Fax:
Practice Address - Street 1:600 NE 8TH ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7317
Practice Address - Country:US
Practice Address - Phone:503-988-5155
Practice Address - Fax:503-988-5185
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL76721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR022959Medicaid