Healthcare Provider Details

I. General information

NPI: 1023747458
Provider Name (Legal Business Name): KENETH MUTUMA MUTHAURA CADC -R
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2022
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78 CENTENNIAL LOOP STE A
EUGENE OR
97401-7900
US

IV. Provider business mailing address

78 CENTENNIAL LOOP STE A
EUGENE OR
97401-7900
US

V. Phone/Fax

Practice location:
  • Phone: 541-393-0777
  • Fax: 541-687-9279
Mailing address:
  • Phone: 541-393-0777
  • Fax: 541-687-9279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberT-22-1651
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: