Provider Demographics
NPI:1992286348
Name:WALLNER, KATHRYN (LPC)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:WALLNER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4425 NE BROADWAY STE 200
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-1425
Mailing Address - Country:US
Mailing Address - Phone:503-258-4555
Mailing Address - Fax:
Practice Address - Street 1:4425 NE BROADWAY STE 200
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-1425
Practice Address - Country:US
Practice Address - Phone:503-258-4555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-23
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X, 106H00000X, 390200000X
ORC7876101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program