Provider Demographics
NPI:1679908883
Name:WILDE, JUSTIN W
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:W
Last Name:WILDE
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 1:1790 W 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-3758
Mailing Address - Country:US
Mailing Address - Phone:541-686-2611
Mailing Address - Fax:
Practice Address - Street 1:2517 MLK JR BLVD
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-5898
Practice Address - Country:US
Practice Address - Phone:541-342-4293
Practice Address - Fax:541-342-4832
Is Sole Proprietor?:No
Enumeration Date:2013-09-06
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor