Provider Demographics
NPI:1548777519
Name:WALBERG, DAVID JAMES
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JAMES
Last Name:WALBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21741 SW CEDAR BROOK WAY
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:OR
Mailing Address - Zip Code:97140-5310
Mailing Address - Country:US
Mailing Address - Phone:907-223-6745
Mailing Address - Fax:
Practice Address - Street 1:1800 NW 169TH PL
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-4848
Practice Address - Country:US
Practice Address - Phone:503-747-2587
Practice Address - Fax:503-746-6323
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-29
Last Update Date:2017-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORABA-IN-10177478106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORABA-IN-10177478OtherSTATE OF OREGON- BARB
RBT-15-03203OtherBEHAVIOR ANALYST CERTIFICATION BOARD