Provider Demographics
NPI:1982097978
Name:WILDER, KESTREL (LMT)
Entity Type:Individual
Prefix:
First Name:KESTREL
Middle Name:
Last Name:WILDER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:A
Other - Last Name:PITTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:1245 CHARNELTON ST STE 7
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-6206
Mailing Address - Country:US
Mailing Address - Phone:541-515-0232
Mailing Address - Fax:541-623-4824
Practice Address - Street 1:1245 CHARNELTON ST
Practice Address - Street 2:#8
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-6214
Practice Address - Country:US
Practice Address - Phone:541-525-0465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-15
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20894225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist