Healthcare Provider Details

I. General information

NPI: 1023974433
Provider Name (Legal Business Name): KETEMA GELANEW DADI SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2025
Last Update Date: 12/30/2025
Certification Date: 12/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 NW 15TH ST APT 138
GRESHAM OR
97030-4886
US

IV. Provider business mailing address

1107 NW 15TH ST APT 138
GRESHAM OR
97030-4886
US

V. Phone/Fax

Practice location:
  • Phone: 408-655-1393
  • Fax:
Mailing address:
  • Phone: 408-655-1393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberE237184
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: