Healthcare Provider Details

I. General information

NPI: 1962323311
Provider Name (Legal Business Name): ANGELICA WETTLIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

348 RUBY AVE
EUGENE OR
97404-2033
US

IV. Provider business mailing address

1750 NEBRASKA AVE BLDG A
GRANTS PASS OR
97527-5700
US

V. Phone/Fax

Practice location:
  • Phone: 541-461-3075
  • Fax:
Mailing address:
  • Phone: 542-244-8557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: