Provider Demographics
NPI:1023218583
Name:WILHELM, LARA NICOLE (MAT)
Entity Type:Individual
Prefix:MRS
First Name:LARA
Middle Name:NICOLE
Last Name:WILHELM
Suffix:
Gender:F
Credentials:MAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 MARKET ST NE
Mailing Address - Street 2:#530
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-1882
Mailing Address - Country:US
Mailing Address - Phone:503-390-5637
Mailing Address - Fax:503-393-3135
Practice Address - Street 1:3000 MARKET ST NE
Practice Address - Street 2:#530
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-1882
Practice Address - Country:US
Practice Address - Phone:503-390-5637
Practice Address - Fax:503-393-3135
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor