Healthcare Provider Details

I. General information

NPI: 1861364119
Provider Name (Legal Business Name): FELASFAW MULUGETA DEGEFU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2025
Last Update Date: 09/18/2025
Certification Date: 09/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1599 NW TOWLE TER
GRESHAM OR
97030-3655
US

IV. Provider business mailing address

1599 NW TOWLE TER
GRESHAM OR
97030-3655
US

V. Phone/Fax

Practice location:
  • Phone: 612-772-7178
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: