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General NPI Number Information
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NPI Number | 1104415405
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Entity Type | Organization
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Legal Business Name | IMANI MENTAL HEALTH AND WELLNESS LLC
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Dates
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Enumeration Date | 01/12/2021
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Last Update Date | 01/25/2021
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Provider Practice Location Address
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Address Line | 3939 NE HANCOCK ST # 202
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City | PORTLAND
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State | OR
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Zip | 972125321
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Country | US
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Telephone | 214-458-1713
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Fax |
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Provider Business Mailing Address
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Address Line | 12063 SW TAYLOR CT
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City | PORTLAND
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State | OR
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Zip | 972255845
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Country | US
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Telephone | 214-458-1713
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Fax |
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Authorized Official
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Title or Position | MENTAL HEALTH NURSE PRACTITIONER
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Name | MS. SUSAN N MBUGUA
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Credential | PMHNP-BC
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Telephone | 214-458-1713
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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