Provider Demographics
NPI:1639537855
Name:WILSON, ANDREA C
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:C
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3425 13TH ST
Mailing Address - Street 2:
Mailing Address - City:BAKER CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97814-1340
Mailing Address - Country:US
Mailing Address - Phone:541-523-7400
Mailing Address - Fax:541-523-4927
Practice Address - Street 1:3425 13TH ST
Practice Address - Street 2:
Practice Address - City:BAKER CITY
Practice Address - State:OR
Practice Address - Zip Code:97814-1340
Practice Address - Country:US
Practice Address - Phone:541-523-7400
Practice Address - Fax:541-523-4927
Is Sole Proprietor?:No
Enumeration Date:2016-02-02
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
OR17-05-48101YA0400X
OR19-QMHA-I-1673101YM0800X
OR21-QMHP-R-0835101YM0800X
ORA12828101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500700231OtherMEDICAID
OR500787454Medicaid