Provider Demographics
NPI:1164882585
Name:WHEATLEY, ALAN
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:
Last Name:WHEATLEY
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 1:12135 SE LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-4064
Mailing Address - Country:US
Mailing Address - Phone:971-231-4611
Mailing Address - Fax:971-231-2164
Practice Address - Street 1:504 SE MYRTLEWOOD LN
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97080-8165
Practice Address - Country:US
Practice Address - Phone:971-231-4611
Practice Address - Fax:971-231-2164
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-26
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC4051101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional