Provider Demographics
NPI:1467587618
Name:WALLACE, SUZANNE KAPUAMAILANI (MSW, ASW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:SUZANNE
Middle Name:KAPUAMAILANI
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MSW, ASW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9911 SE MT.SCOTT BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266
Mailing Address - Country:US
Mailing Address - Phone:503-258-4200
Mailing Address - Fax:
Practice Address - Street 1:9911 SE MOUNT SCOTT BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-6302
Practice Address - Country:US
Practice Address - Phone:503-258-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL34891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical