Provider Demographics
NPI:1205682218
Name:MUTAI, THOMAS K
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:K
Last Name:MUTAI
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 1:16930 SE KELLY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-1432
Mailing Address - Country:US
Mailing Address - Phone:785-861-0023
Mailing Address - Fax:
Practice Address - Street 1:16930 SE KELLY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236-1432
Practice Address - Country:US
Practice Address - Phone:785-861-0023
Practice Address - Fax:607-600-2230
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-29
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDD687301253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency