Healthcare Provider Details

I. General information

NPI: 1164882585
Provider Name (Legal Business Name): ALAN WHEATLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2016
Last Update Date: 02/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 SE MYRTLEWOOD LN
GRESHAM OR
97080-8165
US

IV. Provider business mailing address

12135 SE LINCOLN ST
PORTLAND OR
97216-4064
US

V. Phone/Fax

Practice location:
  • Phone: 971-231-4611
  • Fax: 971-231-2164
Mailing address:
  • Phone: 971-231-4611
  • Fax: 971-231-2164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC4051
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: