Provider Demographics
NPI:1992987754
Name:WALLACE, BETHANY (LCSW)
Entity type:Individual
Prefix:MS
First Name:BETHANY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:
Other - Last Name:BUTLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:3415 SE POWELL BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202
Mailing Address - Country:US
Mailing Address - Phone:503-234-9591
Mailing Address - Fax:541-752-9270
Practice Address - Street 1:4455 NE HIGHWAY 20
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330
Practice Address - Country:US
Practice Address - Phone:541-758-5900
Practice Address - Fax:541-752-9270
Is Sole Proprietor?:No
Enumeration Date:2007-12-03
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
ORL58071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical