Healthcare Provider Details

I. General information

NPI: 1952223729
Provider Name (Legal Business Name): TY RESIDENTIAL WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 SE 212TH AVE
GRESHAM OR
97030-3452
US

IV. Provider business mailing address

15577 SE BOLLAM DR
CLACKAMAS OR
97015-6653
US

V. Phone/Fax

Practice location:
  • Phone: 503-841-0801
  • Fax:
Mailing address:
  • Phone: 503-841-0801
  • 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: MS. TEWABECH TADDESE TEKA
Title or Position: OWNER / PROGRAM ADMINISTRATOR
Credential:
Phone: 503-841-0801