Healthcare Provider Details

I. General information

NPI: 1215481171
Provider Name (Legal Business Name): MIKE WOJTKOWICZ PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2016
Last Update Date: 09/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4455 NE HIGHWAY 20
CORVALLIS OR
97330-9695
US

IV. Provider business mailing address

4455 NE HIGHWAY 20
CORVALLIS OR
97330-9695
US

V. Phone/Fax

Practice location:
  • Phone: 541-758-5900
  • Fax:
Mailing address:
  • Phone: 541-758-7723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3089
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: