Provider Demographics
NPI:1639490022
Name:WILSON, EARL DEAN
Entity Type:Individual
Prefix:
First Name:EARL
Middle Name:DEAN
Last Name:WILSON
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 1:8305 SE MONTEREY AVE
Mailing Address - Street 2:
Mailing Address - City:HAPPY VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97086-7725
Mailing Address - Country:US
Mailing Address - Phone:503-659-4082
Mailing Address - Fax:503-659-4951
Practice Address - Street 1:8305 SE MONTEREY AVE
Practice Address - Street 2:220
Practice Address - City:HAPPY VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97086-7725
Practice Address - Country:US
Practice Address - Phone:503-659-4082
Practice Address - Fax:503-659-4951
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-20
Last Update Date:2010-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR375103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist