=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972416477
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PILLAR RESIDENTIAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2026
-----------------------------------------------------
Last Update Date | 09/24/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20025 MOSSY MEADOWS AVE
-----------------------------------------------------
City | OREGON CITY
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97045-7136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-936-7962
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20025 MOSSY MEADOWS AVE
-----------------------------------------------------
City | OREGON CITY
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97045-7136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-936-7962
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | RESIDENTIAL MANAGER
-----------------------------------------------------
Name | EYUSIAS TSEGAYE WAKE
-----------------------------------------------------
Credential | QMHA
-----------------------------------------------------
Telephone | 240-936-7962
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------