Provider Demographics
NPI:1609390020
Name:WANKE, CHARLES L (CRM)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:L
Last Name:WANKE
Suffix:
Gender:M
Credentials:CRM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4585 SW 185TH AVE
Mailing Address - Street 2:
Mailing Address - City:ALOHA
Mailing Address - State:OR
Mailing Address - Zip Code:97078-1557
Mailing Address - Country:US
Mailing Address - Phone:503-591-9280
Mailing Address - Fax:
Practice Address - Street 1:4585 SW 185TH AVE
Practice Address - Street 2:
Practice Address - City:ALOHA
Practice Address - State:OR
Practice Address - Zip Code:97078-1557
Practice Address - Country:US
Practice Address - Phone:503-591-9280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-27
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OR16-CRM-054101YA0400X, 101YA0400X
ORT-16-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500729602Medicaid
OR500732344Medicaid