Basic Information
| Provider Information | |||||||||
| NPI: | 1679908883 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILDE | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1790 W 11TH AVE | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974023758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416862611 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2517 MLK JR BLVD | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974015898 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413424293 | ||||||||
| FaxNumber: | 5413424832 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2013 | ||||||||
| LastUpdateDate: | 09/06/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | OR | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.