Provider Demographics
NPI:1861792285
Name:WAHLBERG, TRACY (MS)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:WAHLBERG
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:464 SE 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-7021
Mailing Address - Country:US
Mailing Address - Phone:503-746-4690
Mailing Address - Fax:503-846-1182
Practice Address - Street 1:5285 NE ELAM YOUNG PKWY STE B600
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-6496
Practice Address - Country:US
Practice Address - Phone:503-746-4690
Practice Address - Fax:503-846-1182
Is Sole Proprietor?:No
Enumeration Date:2010-11-01
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health