Provider Demographics
NPI:1609390020
Name:WANKE, CHARLES L (CADC I)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:L
Last Name:WANKE
Suffix:
Gender:M
Credentials:CADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1776 SW MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1715
Mailing Address - Country:US
Mailing Address - Phone:503-224-1044
Mailing Address - Fax:503-621-2235
Practice Address - Street 1:17645 NW SAINT HELENS RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97231-1729
Practice Address - Country:US
Practice Address - Phone:503-621-1069
Practice Address - Fax:503-621-0200
Is Sole Proprietor?:No
Enumeration Date:2017-07-27
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18-03-26101YA0400X
ORTHW0001341175T00000X
ORT-16-130101YA0400X
OR16-CRM-054101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500729602Medicaid
OR500732344Medicaid