Provider Demographics
NPI:1811630361
Name:WOLLEAT, TIFFANY DAWN (CADC I/CRM II/PSS)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:DAWN
Last Name:WOLLEAT
Suffix:
Gender:F
Credentials:CADC I/CRM II/PSS
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:DAWN
Other - Last Name:ALMASRI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CADC I/CRM II/PSS
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 1:620 NE 2ND ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7514
Practice Address - Country:US
Practice Address - Phone:971-274-3757
Practice Address - Fax:503-912-5740
Is Sole Proprietor?:No
Enumeration Date:2022-04-13
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000106154175T00000X
OR24-03-11057101YA0400X
OR24-CRM-II-0221101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500806711Medicaid
OR500808225Medicaid