Healthcare Provider Details

I. General information

NPI: 1154189454
Provider Name (Legal Business Name): DESIRE RUKUNDO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2024
Last Update Date: 03/11/2024
Certification Date: 03/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4455 NE HWY 20 CORVALLIS
CORVALLIS OR
97330
US

IV. Provider business mailing address

3415 SE POWELL BLVD
PORTLAND OR
97202-3371
US

V. Phone/Fax

Practice location:
  • Phone: 541-758-5900
  • Fax:
Mailing address:
  • Phone: 503-234-9591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: