Provider Demographics
NPI:1598729097
Name:WADSWORTH, JOHN G (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:G
Last Name:WADSWORTH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 SW MACADAM AVE
Mailing Address - Street 2:SUITE 100D
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4265
Mailing Address - Country:US
Mailing Address - Phone:503-478-0667
Mailing Address - Fax:
Practice Address - Street 1:4700 SW MACADAM AVE
Practice Address - Street 2:SUITE 100D
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4265
Practice Address - Country:US
Practice Address - Phone:503-478-0667
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR9311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000THLGRMedicare ID - Type Unspecified