Provider Demographics
NPI:1265797526
Name:WITTROCK, SHILO VICTORIA
Entity type:Individual
Prefix:
First Name:SHILO
Middle Name:VICTORIA
Last Name:WITTROCK
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 1:508 PEGASUS CT
Mailing Address - Street 2:
Mailing Address - City:MOLALLA
Mailing Address - State:OR
Mailing Address - Zip Code:97038-9213
Mailing Address - Country:US
Mailing Address - Phone:503-750-3363
Mailing Address - Fax:
Practice Address - Street 1:14600 NW CORNELL RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-5442
Practice Address - Country:US
Practice Address - Phone:503-645-3581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker