Provider Demographics
NPI:1568532455
Name:WILSON, HALLE L (DPT, OCS)
Entity Type:Individual
Prefix:MS
First Name:HALLE
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:DPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1795 HIGH ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-5156
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1795 HIGH ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-5156
Practice Address - Country:US
Practice Address - Phone:503-930-4653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4822225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500746101OtherREGENCE HMO
ORM103634OtherPACIFIC SOURCE HEALTH PLA
OR278293Medicaid
OR838969001OtherREGENCE BCBS
WA0210754OtherWA DEPT OF L & I
OR500746101OtherREGENCE HMO