Provider Demographics
NPI:1891532495
Name:WYATT, ASHLEY MARIE
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:MARIE
Last Name:WYATT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ASH
Other - Middle Name:MARIE
Other - Last Name:WYATT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2829 SE BELMONT ST APT 210
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-4070
Mailing Address - Country:US
Mailing Address - Phone:503-367-1861
Mailing Address - Fax:
Practice Address - Street 1:3615 NE GRAND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-2104
Practice Address - Country:US
Practice Address - Phone:503-281-1166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-10
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health