Provider Demographics
NPI:1043683105
Name:WISTER PARK COUNSELING, LLC
Entity Type:Organization
Organization Name:WISTER PARK COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BYRON
Authorized Official - Middle Name:W
Authorized Official - Last Name:KEHLER
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:503-277-9780
Mailing Address - Street 1:11630 SE 40TH AVE
Mailing Address - Street 2:STE. A
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-6195
Mailing Address - Country:US
Mailing Address - Phone:503-715-7308
Mailing Address - Fax:
Practice Address - Street 1:11630 SE 40TH AVE
Practice Address - Street 2:STE. A
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-6195
Practice Address - Country:US
Practice Address - Phone:503-277-9780
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-10
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare