Provider Demographics
NPI:1962851212
Name:DESSALEGNE, MIHRETU
Entity Type:Individual
Prefix:
First Name:MIHRETU
Middle Name:
Last Name:DESSALEGNE
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 1:2355 STATE ST STE 101
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4541
Mailing Address - Country:US
Mailing Address - Phone:971-267-2345
Mailing Address - Fax:
Practice Address - Street 1:2355 STATE ST STE 101
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4541
Practice Address - Country:US
Practice Address - Phone:971-267-2345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR6074101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health