Individual
WYATT FERNELIUS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
QMHA
Contact information
Practice address
2640 NW ALEXANDRA AVE, PORTLAND, OR 97210-1289
(503) 731-3978
(503) 239-1252
Mailing address
PO BOX 10027, PORTLAND, OR 97296-0027
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
—
—
Other
Enumeration date
07/21/2017
Last updated
07/21/2017
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