Provider Demographics
NPI:1861907842
Name:OKUMU, GORDON ODUOR
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:ODUOR
Last Name:OKUMU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 SW RAMSEY AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-5500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:348 RUBY AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97404-2033
Practice Address - Country:US
Practice Address - Phone:541-956-4943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-12
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR101Y00000XMedicaid