Provider Demographics
NPI:1053060772
Name:MACON, WYMAN
Entity Type:Individual
Prefix:
First Name:WYMAN
Middle Name:
Last Name:MACON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 SE CESAR E CHAVEZ BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-3216
Mailing Address - Country:US
Mailing Address - Phone:503-231-7480
Mailing Address - Fax:
Practice Address - Street 1:605 SE CESAR E CHAVEZ BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-3216
Practice Address - Country:US
Practice Address - Phone:503-231-7480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-21
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist