Provider Demographics
NPI:1730430612
Name:WILSON, HEIDI (ND)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 NE 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2829
Mailing Address - Country:US
Mailing Address - Phone:503-239-8181
Mailing Address - Fax:
Practice Address - Street 1:314 NE 19TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-2829
Practice Address - Country:US
Practice Address - Phone:503-239-8181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-02
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 261QM0801X
OR4464175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)