Provider Demographics
NPI:1912887621
Name:WOLDU, EYERUSALEM
Entity type:Individual
Prefix:
First Name:EYERUSALEM
Middle Name:
Last Name:WOLDU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 E BERKELEY ST
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:OR
Mailing Address - Zip Code:97027-2419
Mailing Address - Country:US
Mailing Address - Phone:769-447-7780
Mailing Address - Fax:
Practice Address - Street 1:12684 SE MAJESTIC LN
Practice Address - Street 2:
Practice Address - City:HAPPY VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97086-9313
Practice Address - Country:US
Practice Address - Phone:769-447-7780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-03
Last Update Date:2025-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness