Provider Demographics
NPI:1558828772
Name:WOOTEN, WILLIAM T
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:T
Last Name:WOOTEN
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 1:6150 SW ALICE LN APT 205A
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97008-4677
Mailing Address - Country:US
Mailing Address - Phone:971-270-6106
Mailing Address - Fax:
Practice Address - Street 1:2167 NW 185TH AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-7074
Practice Address - Country:US
Practice Address - Phone:503-828-1311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-24
Last Update Date:2019-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24864225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist