Provider Demographics
NPI:1669492344
Name:WAHL, JAMES M
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:M
Last Name:WAHL
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 1:320 CENTRAL AVE.
Mailing Address - Street 2:SUITE 418
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-9490
Mailing Address - Country:US
Mailing Address - Phone:541-269-1334
Mailing Address - Fax:541-269-7824
Practice Address - Street 1:320 CENTRAL AVE.
Practice Address - Street 2:SUITE 418
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-9490
Practice Address - Country:US
Practice Address - Phone:541-269-1334
Practice Address - Fax:541-269-7824
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0257103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR214288OtherOMAP PROVIDER NUMBER