Individual
DR. PETER FREDERICK WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PSY.D.
Contact information
Practice address
1217 NE BURNSIDE RD, BLDG B, SUITE 401, GRESHAM, OR 97030-6722
(503) 666-8832
(503) 669-8641
Mailing address
PO BOX 82819, PORTLAND, OR 97282-0819
(503) 233-5405
(503) 233-2696
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
1467
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
131734
PERSONAL MEDICARE #
OR
05
—
164936
—
OR
Enumeration date
09/29/2006
Last updated
07/08/2007
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