Provider Demographics
NPI:1497153076
Name:WILDER, ROGER
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
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 1:3871 FAIRVIEW INDUSTRIAL DR SE
Mailing Address - Street 2:ST #105
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302
Mailing Address - Country:US
Mailing Address - Phone:503-391-9765
Mailing Address - Fax:503-391-2019
Practice Address - Street 1:3871 FAIRVIEW INDUSTRIAL DR SE
Practice Address - Street 2:ST #105
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-1180
Practice Address - Country:US
Practice Address - Phone:503-391-9765
Practice Address - Fax:503-391-2019
Is Sole Proprietor?:No
Enumeration Date:2014-12-12
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13-09-59101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)