Basic Information
| Provider Information | |||||||||
| NPI: | 1053605667 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLINGTON | ||||||||
| FirstName: | ARIN | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA MFT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CLARK | ||||||||
| OtherFirstName: | ARIN | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MA MFT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4585 SW 185TH AVE | ||||||||
| Address2: | |||||||||
| City: | ALOHA | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970781557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035919280 | ||||||||
| FaxNumber: | 5036191949 | ||||||||
| Practice Location | |||||||||
| Address1: | 4585 SW 185TH AVE | ||||||||
| Address2: | |||||||||
| City: | ALOHA | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970781557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035919280 | ||||||||
| FaxNumber: | 5036191949 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2011 | ||||||||
| LastUpdateDate: | 10/20/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101YM0800X | OR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 123190 | 05 | OR | MEDICAID |