Provider Demographics
NPI:1982940169
Name:WONDERLICK, BRET ANTHONY (MS CCC-A)
Entity type:Individual
Prefix:MR
First Name:BRET
Middle Name:ANTHONY
Last Name:WONDERLICK
Suffix:
Gender:M
Credentials:MS CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2702 NE BRYCE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-1638
Mailing Address - Country:US
Mailing Address - Phone:503-567-9392
Mailing Address - Fax:
Practice Address - Street 1:1849 NW KEARNEY ST
Practice Address - Street 2:SUITE 200
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-1453
Practice Address - Country:US
Practice Address - Phone:971-570-5387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-17
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21957231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist