Healthcare Provider Details

I. General information

NPI: 1093278111
Provider Name (Legal Business Name): VIVA WHEATON PSYD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2019
Last Update Date: 10/14/2020
Certification Date: 10/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 E. HANCOCK ST
NEWBERG OR
97132
US

IV. Provider business mailing address

16485 NE LEANDER DR
SHERWOOD OR
97140-8579
US

V. Phone/Fax

Practice location:
  • Phone: 503-860-5874
  • Fax:
Mailing address:
  • Phone: 503-860-5874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. VIVA WHEATON
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PSY.D.
Phone: 503-860-5874