Earnest Wallace III, PSS

Primary specialty

Peer SpecialistTaxonomy code 175T00000X

License

111712 Issued in OR

Practice address

5201 SW Westgate Dr Ste 100
Portland, OR 97221-2424

Phone

(469) 297-0096

NPI assigned

Jul 15, 2024

Last updated

Jul 15, 2024By the provider in NPPES

Sex

Male

Sole proprietor

Yes

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

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Lighthouse Counseling Center LLC

  dba Lighthouse Counseling

  • Adult Mental Health Clinic/Center
  • Portland, OR
  • NPI 1366136541
  NPD Authorized official

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

{
    "created_epoch": "1721001600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1721001600000",
    "number": "1730927815",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "423 MCKINLEY ST",
            "city": "CEDAR HILL",
            "state": "TX",
            "postal_code": "751042287"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5201 SW WESTGATE DR STE 100",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972212424",
            "telephone_number": "469-297-0096"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "EARNEST",
        "name_suffix": "III",
        "credential": "PSS",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2024-07-15",
        "last_updated": "2024-07-15",
        "certification_date": "2024-07-15",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "175T00000X",
            "taxonomy_group": "",
            "desc": "Peer Specialist",
            "state": "OR",
            "license": "111712",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Blake Wallace, LCSW
• Candor Wallace
• Christina Marie Wallace, RPH
• Claire Wallace, MA LPC
• Claudette F Wallace, CADC III
• Elizabeth Frances Wallace, MA, LPC
• Elizabeth Spagat Wallace, ND,LAC
• Erin Wallace, OTD, OTR/L
• Harrison James Wallace
• Jacqueline Vasquez Wallace

• Peer Specialist in Portland, OR
• Providers in Portland, OR by specialty
• Peer Specialist in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 15, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.