Healthcare Provider Details

I. General information

NPI: 1164996294
Provider Name (Legal Business Name): KASEJA WILDER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2019
Last Update Date: 04/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 KINGSWOOD AVE
EUGENE OR
97405-3541
US

IV. Provider business mailing address

575 KINGSWOOD AVE
EUGENE OR
97405-3541
US

V. Phone/Fax

Practice location:
  • Phone: 541-844-5038
  • Fax:
Mailing address:
  • Phone: 541-844-5038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
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: KASEJA LAURINE WILDER
Title or Position: OWNER
Credential: LCSW
Phone: 541-844-5038