Blake Wallace, LCSW

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

L18555 Issued in OR

Practice address

3500 NE Martin Luther King Jr Blvd Ste 200
Portland, OR 97212-2093

Phone

(503) 327-8205

Fax

(503) 254-4882

NPI assigned

Jun 27, 2024

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Medicare enrollment (NPD)

Enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1719446400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1786320000000",
    "number": "1518702976",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3500 NE MARTIN LUTHER KING JR BLVD STE 200",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972122093",
            "telephone_number": "503-327-8205"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3500 NE MARTIN LUTHER KING JR BLVD STE 200",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972122093",
            "telephone_number": "503-327-8205",
            "fax_number": "503-254-4882"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "BLAKE",
        "credential": "LCSW",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2024-06-27",
        "last_updated": "2026-08-10",
        "certification_date": "2026-08-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "OR",
            "license": "A15334",
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "OR",
            "license": "L18555",
            "primary": true
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "OR",
            "license": "24-QMHP-R-2920",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Kimberly Lynn Wall, LCSW
• Michael Wall
• Michael Abraham Wall, MD
• Agustina Wallace
• Aisha Wallace
• Candor Wallace
• Christina Marie Wallace, RPH
• Claire Wallace, MA LPC
• Claudette F Wallace, CADC III
• Earnest Wallace III, PSS

• Clinical Social Worker in Portland, OR
• Providers in Portland, OR by specialty
• Clinical Social Worker in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 10, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.