Provider Demographics
NPI:1710025820
Name:WOLFINGTON, THEODORE JAY
Entity type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:JAY
Last Name:WOLFINGTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4822 NE 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-4620
Mailing Address - Country:US
Mailing Address - Phone:503-287-0606
Mailing Address - Fax:
Practice Address - Street 1:4822 NE 12TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-4620
Practice Address - Country:US
Practice Address - Phone:503-287-0606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered372600000XNursing Service Related ProvidersAdult Companion