Provider Demographics
NPI:1235181868
Name:WILDWOOD PSYCHIATRIC RESOURCE CENTER
Entity Type:Organization
Organization Name:WILDWOOD PSYCHIATRIC RESOURCE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANN
Authorized Official - Middle Name:J
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-690-8606
Mailing Address - Street 1:PO BOX 610
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97024-0610
Mailing Address - Country:US
Mailing Address - Phone:503-963-1221
Mailing Address - Fax:503-230-1541
Practice Address - Street 1:16110 SW REGATTA LN
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-8942
Practice Address - Country:US
Practice Address - Phone:503-629-2131
Practice Address - Fax:503-617-9379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR054123000OtherBLUE CROSS NUMBER
OR0000WCBBQMedicare ID - Type UnspecifiedGROUP NUMBER