Basic Information
Provider Information | |||||||||
NPI: | 1235181868 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WILDWOOD PSYCHIATRIC RESOURCE CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 610 | ||||||||
Address2: |   | ||||||||
City: | FAIRVIEW | ||||||||
State: | OR | ||||||||
PostalCode: | 970240610 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5039631221 | ||||||||
FaxNumber: | 5032301541 | ||||||||
Practice Location | |||||||||
Address1: | 16110 SW REGATTA LN | ||||||||
Address2: |   | ||||||||
City: | BEAVERTON | ||||||||
State: | OR | ||||||||
PostalCode: | 970068942 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5036292131 | ||||||||
FaxNumber: | 5036179379 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/16/2006 | ||||||||
LastUpdateDate: | 07/23/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HOWARD | ||||||||
AuthorizedOfficialFirstName: | ANN | ||||||||
AuthorizedOfficialMiddleName: | J. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 5036908606 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |   |
ID Information
ID | Type | State | Issuer | Description | 054123000 | 01 | OR | BLUE CROSS NUMBER | OTHER |