Basic Information
| Provider Information | |||||||||
| NPI: | 1558616524 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCNAIR | ||||||||
| FirstName: | WYNDHAM | ||||||||
| MiddleName: | PIERCE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CADC I | ||||||||
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| Mailing Information | |||||||||
| Address1: | P O BOX 3007 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035351150 | ||||||||
| FaxNumber: | 5035351191 | ||||||||
| Practice Location | |||||||||
| Address1: | 1312 SW WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972052327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035351150 | ||||||||
| FaxNumber: | 5035351191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2012 | ||||||||
| LastUpdateDate: | 07/17/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 11-06--50 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 11-06-50 | 01 | OR | ACCBO CADC I A&D CERTIFICATION | OTHER |