Healthcare Provider Details

I. General information

NPI: 1598126310
Provider Name (Legal Business Name): WILD GEESE MENTAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2016
Last Update Date: 03/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

636 SW 2ND ST
CORVALLIS OR
97333-4442
US

IV. Provider business mailing address

636 SW 2ND ST
CORVALLIS OR
97333-4442
US

V. Phone/Fax

Practice location:
  • Phone: 541-636-2855
  • Fax: 541-610-1506
Mailing address:
  • Phone: 541-636-2855
  • Fax: 541-610-1506

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number201150061NP
License Number StateOR

VIII. Authorized Official

Name: AYELET AMITTAY
Title or Position: REGISTERED AGENT
Credential: PMHNP-BC
Phone: 541-636-2855