Basic Information
| Provider Information | |||||||||
| NPI: | 1801433792 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | SANYELLE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SANDUSKY | ||||||||
| OtherFirstName: | SANYELLE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 941 W 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974024634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417356345 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1790 W 11TH AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974023871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416862688 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2019 | ||||||||
| LastUpdateDate: | 12/10/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/10/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.