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General NPI Number Information
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NPI Number | 1952223729
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Entity Type | Organization
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Legal Business Name | TY RESIDENTIAL WELLNESS LLC
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Dates
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Enumeration Date | 07/27/2026
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Last Update Date | 07/27/2026
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Provider Practice Location Address
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Address Line | 1211 SE 212TH AVE
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City | GRESHAM
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State | OR
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Zip | 97030-3452
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Country | US
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Telephone | 503-841-0801
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Fax |
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Provider Business Mailing Address
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Address Line | 15577 SE BOLLAM DR
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City | CLACKAMAS
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State | OR
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Zip | 97015-6653
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Country | US
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Telephone | 503-841-0801
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Fax |
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Authorized Official
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Title or Position | OWNER / PROGRAM ADMINISTRATOR
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Name | MS. TEWABECH TADDESE TEKA
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Credential |
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Telephone | 503-841-0801
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number |
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License Number State |
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