Provider Demographics
NPI:1659538189
Name:WALLACE, ELIZABETH FRANCES (MA, LPC)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:FRANCES
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:MISS
Other - First Name:ELIZABETH
Other - Middle Name:FRANCES
Other - Last Name:JACOB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6360 SW MERLIN CT
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-4942
Mailing Address - Country:US
Mailing Address - Phone:503-317-2498
Mailing Address - Fax:
Practice Address - Street 1:6360 SW MERLIN CT
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-4942
Practice Address - Country:US
Practice Address - Phone:503-317-2498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-21
Last Update Date:2021-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC2083101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR164936Medicaid
OR164936Medicaid