Provider Demographics
NPI:1801209606
Name:WILDER, KENLIN (MBA, MS MHC)
Entity Type:Individual
Prefix:
First Name:KENLIN
Middle Name:
Last Name:WILDER
Suffix:
Gender:F
Credentials:MBA, MS MHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8528 NW MENDENHALL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-4191
Mailing Address - Country:US
Mailing Address - Phone:508-364-8867
Mailing Address - Fax:
Practice Address - Street 1:8528 NW MENDENHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-4191
Practice Address - Country:US
Practice Address - Phone:508-364-8867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-09
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health