Provider Demographics
NPI:1669112298
Name:WILDE, ROSYLN CONTESSLA (LCSW)
Entity type:Individual
Prefix:
First Name:ROSYLN
Middle Name:CONTESSLA
Last Name:WILDE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9054 N NEW YORK AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-3036
Mailing Address - Country:US
Mailing Address - Phone:503-462-4440
Mailing Address - Fax:
Practice Address - Street 1:9054 N NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97203-3036
Practice Address - Country:US
Practice Address - Phone:971-412-2620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-31
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL111141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical