Healthcare Provider Details

I. General information

NPI: 1033902382
Provider Name (Legal Business Name): WILD PELORIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2025
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12035 SE GRAND VISTA DR
CLACKAMAS OR
97015-8272
US

IV. Provider business mailing address

12035 SE GRAND VISTA DR
CLACKAMAS OR
97015-8272
US

V. Phone/Fax

Practice location:
  • Phone: 512-966-4440
  • Fax:
Mailing address:
  • Phone: 512-966-4440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: JAMIE WATSON
Title or Position: CLINICAL DIRECTOR
Credential: LMFT, RPT-S
Phone: 512-966-4440