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General NPI Number Information
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NPI Number | 1821205246
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Entity Type | Individual
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Provider Name | MS. GAIL RENEE WILSON
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Gender | Female
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Dates
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Enumeration Date | 05/16/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 2614 SE 115TH AVE APT 2
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City | PORTLAND
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State | OR
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Zip | 97266-1176
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Country | US
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Telephone | 503-757-4245
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Fax |
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Provider Business Mailing Address
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Address Line | 2614 SE 115TH AVE APT 2
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City | PORTLAND
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State | OR
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Zip | 97266-1176
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Country | US
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Telephone | 503-757-4245
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Fax |
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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 | 3245S0500X
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Taxonomy Name | Children's Substance Abuse Rehabilitation Facility
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License Number | 3245S0500X
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License Number State | OR
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