Provider Demographics
NPI:1972337475
Name:SEBASTE, WALTER A (PCA)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:A
Last Name:SEBASTE
Suffix:
Gender:M
Credentials:PCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6224 SE 91ST AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-5212
Mailing Address - Country:US
Mailing Address - Phone:503-573-9509
Mailing Address - Fax:
Practice Address - Street 1:6224 SE 91ST AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-5212
Practice Address - Country:US
Practice Address - Phone:503-573-9509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-27
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR9739101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional