Doctor Name: | MARYJANE WILT |
NPI Number: | 1003106881 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | LPC |
License Number: | C2002 |
Business Practice Address: | 212 Ne 80th Ave Portland, OR - 972137016 |
Business Phone Number: | 9712551559 |
Business Fax Number: | 9712550339 |
Mailing Address: | 212 Ne 80th Ave, PORTLAND |
State: | OR |
Postal Code: | 972137016 |
Phone Number: | 9712551559 |
Fax Number: | 9712550339 |
NPI Enumeration Date: | 04/13/2011 |
NPI Last Update Date: | 04/13/2011 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 101YM0800X |
License Number: | C2002 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | OR |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Counselor |
Taxonomy Specialization: | Mental Health |
Taxonomy Definition: |