Healthcare Provider Details

I. General information

NPI: 1962334003
Provider Name (Legal Business Name): EJEGAYEHU MULUNEH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 SE 214TH AVE
GRESHAM OR
97030-3424
US

IV. Provider business mailing address

830 SE 214TH AVE
GRESHAM OR
97030-3424
US

V. Phone/Fax

Practice location:
  • Phone: 503-984-8217
  • Fax:
Mailing address:
  • Phone: 503-984-8217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: