Healthcare Provider Details

I. General information

NPI: 1821205246
Provider Name (Legal Business Name): MS. GAIL RENEE WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2614 SE 115TH AVE APT 2
PORTLAND OR
97266-1176
US

IV. Provider business mailing address

2614 SE 115TH AVE APT 2
PORTLAND OR
97266-1176
US

V. Phone/Fax

Practice location:
  • Phone: 503-757-4245
  • Fax:
Mailing address:
  • Phone: 503-757-4245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number3245S0500X
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: