Provider Demographics
NPI:1164532230
Name:WILDER, PATRICK ROBERT
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:ROBERT
Last Name:WILDER
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 1:420 NW 11TH AVE
Mailing Address - Street 2:#702
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2957
Mailing Address - Country:US
Mailing Address - Phone:503-331-9493
Mailing Address - Fax:
Practice Address - Street 1:3500 N INTERSTATE AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1196
Practice Address - Country:US
Practice Address - Phone:503-285-9321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL35991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical