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General NPI Number Information
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NPI Number | 1639490022
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Entity Type | Individual
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Provider Name | EARL DEAN WILSON
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Gender | Male
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Dates
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Enumeration Date | 06/20/2010
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Last Update Date | 06/20/2010
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Provider Practice Location Address
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Address Line | 8305 SE MONTEREY AVE 220
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City | HAPPY VALLEY
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State | OR
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Zip | 97086-7725
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Country | US
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Telephone | 503-659-4082
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Fax | 503-659-4951
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Provider Business Mailing Address
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Address Line | 8305 SE MONTEREY AVE
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City | HAPPY VALLEY
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State | OR
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Zip | 97086-7725
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Country | US
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Telephone | 503-659-4082
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Fax | 503-659-4951
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 375
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License Number State | OR
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