Provider Demographics
NPI:1407863947
Name:WALTY, SHEILA MARIA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:SHEILA
Middle Name:MARIA
Last Name:WALTY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 NW IRVING ST
Mailing Address - Street 2:STE 200
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2275
Mailing Address - Country:US
Mailing Address - Phone:503-842-7855
Mailing Address - Fax:971-339-0401
Practice Address - Street 1:1455 NW IRVING ST
Practice Address - Street 2:STE 200
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-2275
Practice Address - Country:US
Practice Address - Phone:503-842-7855
Practice Address - Fax:971-339-0401
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2019-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0234101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500636891Medicaid
OR500636891Medicaid