Provider Demographics
NPI:1073615621
Name:STALLER, DENNIS (MSW)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:
Last Name:STALLER
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4206 SE 33RD AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-3439
Mailing Address - Country:US
Mailing Address - Phone:503-220-8262
Mailing Address - Fax:503-273-5285
Practice Address - Street 1:3710 SW US VETERANS HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-2964
Practice Address - Country:US
Practice Address - Phone:503-220-8262
Practice Address - Fax:503-273-5285
Is Sole Proprietor?:No
Enumeration Date:2006-09-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS26143104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker