Provider Demographics
NPI:1952871774
Name:WIGHT, MATTHEW JAMES
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JAMES
Last Name:WIGHT
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 1:511 MAIN ST STE 201
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-1830
Mailing Address - Country:US
Mailing Address - Phone:503-655-1029
Mailing Address - Fax:
Practice Address - Street 1:511 MAIN ST STE 201
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-1830
Practice Address - Country:US
Practice Address - Phone:503-655-1029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-05
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT-18-177101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)