Active NPI
Athena Leeann Wildenborg, T-23-2498
- Counselor
- Roseville, CA
National Provider Identifier
1326812488
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Counselor
- License
- T-23-2498
- Practice address
- 200 La Loma CT
Roseville, CA 95678-2908 - Phone
- (360) 214-4102
- NPI assigned
- Nov 9, 2023
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Counselor | 101Y00000X | T-23-2498 | OR | Primary |
Addresses
Primary practice location
200 La Loma CT
Roseville, CA 95678-2908
Mailing address
1122 NE 122ND Ave Ste A102
Portland, OR 97230-2082
Phone (503) 954-1890
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| T-23-2498 | OR | MD | Counselor |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Sober Living Oregon Recovery Center | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Substance Use Disorder Rehabilitation Clinic/Center
- Oregon City, OR
- NPI 1073081881
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1699488000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1699488000000",
"number": "1326812488",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1122 NE 122ND AVE STE A102",
"city": "PORTLAND",
"state": "OR",
"postal_code": "972302082",
"telephone_number": "503-954-1890"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "200 LA LOMA CT",
"city": "ROSEVILLE",
"state": "CA",
"postal_code": "956782908",
"telephone_number": "360-214-4102"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WILDENBORG",
"first_name": "ATHENA",
"middle_name": "LEEANN",
"credential": "T-23-2498",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2023-11-09",
"last_updated": "2023-11-09",
"certification_date": "2023-11-09",
"status": "A"
},
"taxonomies": [
{
"code": "101Y00000X",
"taxonomy_group": "",
"desc": "Counselor",
"state": "OR",
"license": "T-23-2498",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Roseville, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 9, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.