Basic Information
| Provider Information | |||||||||
| NPI: | 1457004111 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MWANGIN | ||||||||
| FirstName: | TAPITA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19316 NE GLISAN ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972307855 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 912 NE KELLY AVE # 100C | ||||||||
| Address2: | |||||||||
| City: | GRESHAM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970305629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039125502 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2022 | ||||||||
| LastUpdateDate: | 02/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 106E00000X | N | 106S00000X | Y |
No ID Information.