Provider Demographics
NPI:1598126310
Name:WILD GEESE MENTAL HEALTH LLC
Entity Type:Organization
Organization Name:WILD GEESE MENTAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED AGENT
Authorized Official - Prefix:
Authorized Official - First Name:AYELET
Authorized Official - Middle Name:
Authorized Official - Last Name:AMITTAY
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:541-636-2855
Mailing Address - Street 1:636 SW 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97333-4442
Mailing Address - Country:US
Mailing Address - Phone:541-636-2855
Mailing Address - Fax:541-610-1506
Practice Address - Street 1:636 SW 2ND ST
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333-4442
Practice Address - Country:US
Practice Address - Phone:541-636-2855
Practice Address - Fax:541-610-1506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-08
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201150061NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty