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General NPI Number Information
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NPI Number | 1043106610
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Entity Type | Organization
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Legal Business Name | WANDERLUST PSYCHIATRY
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Dates
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Enumeration Date | 06/17/2025
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Last Update Date | 06/17/2025
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Provider Practice Location Address
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Address Line | 5331 S MACADAM AVE STE 258-1159
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City | PORTLAND
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State | OR
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Zip | 97239-6104
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Country | US
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Telephone | 503-966-3135
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Fax | 503-300-4645
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Provider Business Mailing Address
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Address Line | 5331 S MACADAM AVE STE 258-1159
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City | PORTLAND
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State | OR
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Zip | 97239-6104
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Country | US
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Telephone | 503-966-3135
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Fax | 503-300-4645
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Authorized Official
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Title or Position | OWNER / PMHNP
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Name | CARLI SAWYER VANDENHOUTEN
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Credential | PMHNP
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Telephone | 503-516-3977
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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