Healthcare Provider Details

I. General information

NPI: 1417898941
Provider Name (Legal Business Name): IMANI RESIDENTIAL TREATMENT HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2026
Last Update Date: 04/01/2026
Certification Date: 04/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14325 SW WILSON DR
BEAVERTON OR
97008-6140
US

IV. Provider business mailing address

14325 SW WILSON DR
BEAVERTON OR
97008-6140
US

V. Phone/Fax

Practice location:
  • Phone: 971-357-1234
  • Fax:
Mailing address:
  • Phone: 971-357-1234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. SUSAN MBUGUA
Title or Position: ADMINSTRATOR
Credential: PMHNP-BC
Phone: 214-458-1713