Provider Demographics
NPI:1992897490
Name:WILSON, PETER FREDERICK (PSYD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:FREDERICK
Last Name:WILSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 82819
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97282-0819
Mailing Address - Country:US
Mailing Address - Phone:503-233-5405
Mailing Address - Fax:503-233-2696
Practice Address - Street 1:1217 NE BURNSIDE RD
Practice Address - Street 2:BLDG B, SUITE 401
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-6722
Practice Address - Country:US
Practice Address - Phone:503-666-8832
Practice Address - Fax:503-669-8641
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1467103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR164936Medicaid
OR131734OtherPERSONAL MEDICARE #
OR164936Medicaid