Provider Demographics
NPI:1265253082
Name:WILD HEARTS PDX
Entity type:Organization
Organization Name:WILD HEARTS PDX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHANAKO
Authorized Official - Middle Name:
Authorized Official - Last Name:DEVOLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-887-6255
Mailing Address - Street 1:4531 SE BELMONT ST STE 119
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-1675
Mailing Address - Country:US
Mailing Address - Phone:503-887-6255
Mailing Address - Fax:
Practice Address - Street 1:4531 SE BELMONT ST STE 119
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-1675
Practice Address - Country:US
Practice Address - Phone:503-887-6255
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-23
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)