MEDICARE: CLEMENT MUCYO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	175T00000X	Peer Specialist

General Provider Information

NPI Number	:	1720851637
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLEMENT MUCYO

Provider Business Mailing Address
First Line	:	80 SE MADISON ST STE 242
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97214-4527
Country	:	US
Telephone Number	:	240-923-0453
Fax Number	:

Provider Business Practice Location Address
First Line	:	80 SE MADISON ST STE 242
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97214-4527
Country	:	US
Telephone Number	:	240-923-0453
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/02/2023
Last Update Date	:	11/02/2023

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Directions to “ CLEMENT MUCYO ” Practice Location

Language	Start Address	Practice Location

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