Wild Hearts PDX

Primary specialty

Mental Health Clinic/Center (Including Community Mental Health Center)Taxonomy code 261QM0801X

Legal business name

WILD HEARTS PDX

Practice address

4531 SE Belmont St Ste 119
Portland, OR 97215-1675

Phone

(503) 887-6255

NPI assigned

Oct 23, 2024

Last updated

Oct 23, 2024By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Shanako DevollNPI 1316254022

Title

President

Phone

(503) 887-6255

Specialties & licenses 1

Addresses

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Shanako Devoll, CADC I, QMHA

  • Mental Health Counselor
  • Portland, OR
  • NPI 1316254022
  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1729641600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1729641600000",
    "number": "1265253082",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4531 SE BELMONT ST STE 119",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972151675",
            "telephone_number": "503-887-6255"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4531 SE BELMONT ST STE 119",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972151675",
            "telephone_number": "503-887-6255"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WILD HEARTS PDX",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-10-23",
        "last_updated": "2024-10-23",
        "certification_date": "2024-10-23",
        "status": "A",
        "authorized_official_last_name": "DEVOLL",
        "authorized_official_first_name": "SHANAKO",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "503-887-6255"
    },
    "taxonomies": [
        {
            "code": "261QM0801X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Mental Health (Including Community Mental Health Center)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Tim I Wilcox, M.D.
• Elijah Wilcynski
• Wild Foliage Massage & Botanicals LLC
• Wild Hart Massage LLC
• Wild Heart Natural Medicine LLC
• Wild Hearts Wellness LLC
• Wild Lilac Child Development Community
• Wild Moss Wellness LLC
• Wild Naturopathic
• Wild Open Being, LLC

• Mental Health Clinic/Center (Including Community Mental Health Center) in Portland, OR
• Providers in Portland, OR by specialty
• Mental Health Clinic/Center (Including Community Mental Health Center) in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 23, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.