Healthcare Provider Details

I. General information

NPI: 1316819733
Provider Name (Legal Business Name): EYUEL ETANSA AFH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2025
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12161 SE JOHANSEN CT
CLACKAMAS OR
97015-7226
US

IV. Provider business mailing address

12161 SE JOHANSEN CT
CLACKAMAS OR
97015-7226
US

V. Phone/Fax

Practice location:
  • Phone: 214-586-9800
  • Fax:
Mailing address:
  • Phone: 214-586-9800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: EYUEL ETANSA
Title or Position: DIRECTOR
Credential:
Phone: 214-586-9800