Provider Demographics
NPI:1467616763
Name:CODY-WALD, GWENN TIANA (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:GWENN
Middle Name:TIANA
Last Name:CODY-WALD
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:GWENN
Other - Middle Name:
Other - Last Name:CODY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:819 SE MORRISON ST STE 250
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-6315
Mailing Address - Country:US
Mailing Address - Phone:503-230-0518
Mailing Address - Fax:503-200-1438
Practice Address - Street 1:819 SE MORRISON ST STE 250
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-6315
Practice Address - Country:US
Practice Address - Phone:503-230-0518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-15
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical