Provider Demographics
NPI:1306412630
Name:WILMARTH, SAMUEL JAMES
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:JAMES
Last Name:WILMARTH
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 1:7555 SW HERMOSO WAY STE 120
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8684
Mailing Address - Country:US
Mailing Address - Phone:503-345-3260
Mailing Address - Fax:
Practice Address - Street 1:7555 SW HERMOSO WAY STE 120
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8684
Practice Address - Country:US
Practice Address - Phone:503-345-3260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-27
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC8858101YP2500X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty