Provider Demographics
NPI:1093592875
Name:WILSON, CALEB BRUCE (LMT)
Entity Type:Individual
Prefix:MR
First Name:CALEB
Middle Name:BRUCE
Last Name:WILSON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3615 SE HAWTHORNE BLVD APT 7
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-5160
Mailing Address - Country:US
Mailing Address - Phone:352-502-6036
Mailing Address - Fax:
Practice Address - Street 1:2100 NE BROADWAY ST STE 125
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1500
Practice Address - Country:US
Practice Address - Phone:503-477-8222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-13
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR26664225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist