NPIMap

Organization Active NPI

Imani Mental Health and Wellness LLC

  • Psychiatric/Mental Health Nurse Practitioner
  • Portland, OR
National Provider Identifier
1104415405
Registry record updated Jan 25, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatric/Mental Health Nurse PractitionerTaxonomy code 363LP0808X
Legal business name
IMANI MENTAL HEALTH AND WELLNESS LLC
Practice address
3939 NE Hancock St # 202
Portland, OR 97212-5321
Phone
(214) 458-1713
NPI assigned
Jan 12, 2021
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 25, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Ms. Susan N Mbugua, PMHNP-BCNPI 1932503539
Title
Mental Health Nurse Practitioner
Phone
(214) 458-1713

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Psychiatric/Mental Health Nurse PractitionerGroup: 193400000X SINGLE SPECIALTY GROUP 363LP0808X Primary

Addresses

Primary practice location

3939 NE Hancock St # 202
Portland, OR 97212-5321

Mailing address

12063 SW Taylor CT
Portland, OR 97225-5845
Phone (214) 458-1713

Electronic endpoints 1

TypeEndpointUseAffiliation
CONNECT URL imanimentalhealthwellness@gmail.com Health Information Exchange (HIE)

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OR

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20210202003254 OR Part B Supplier - Clinic/Group Practice 5597179556 Receives reassigned benefits from 1 practitioner
Practice locations: Portland, OR

National Provider Directory

National Provider Directory
Tax ID family
Imani Mental HLTH and Well2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Locations

3939 NE Hancock St
#202
Portland, OR 97212
Phone (214) 458-1713

3939 NE Hancock St
Ste 202
Portland, OR 97212
Phone (503) 545-6465

Ownership & related parties

Subparts reporting this organization as parent 1

Organizations that report themselves as subparts in NPPES and name this organization, in the same state, as their parent.

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1610409600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1611532800000",
    "number": "1104415405",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12063 SW TAYLOR CT",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972255845",
            "telephone_number": "214-458-1713"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3939 NE HANCOCK ST # 202",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972125321",
            "telephone_number": "214-458-1713"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IMANI MENTAL HEALTH AND WELLNESS LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-01-12",
        "last_updated": "2021-01-25",
        "certification_date": "2021-01-25",
        "status": "A",
        "authorized_official_last_name": "MBUGUA",
        "authorized_official_first_name": "SUSAN",
        "authorized_official_middle_name": "N",
        "authorized_official_title_or_position": "MENTAL HEALTH NURSE PRACTITIONER",
        "authorized_official_telephone_number": "214-458-1713",
        "authorized_official_name_prefix": "Ms.",
        "authorized_official_credential": "PMHNP-BC"
    },
    "taxonomies": [
        {
            "code": "363LP0808X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "imanimentalhealthwellness@gmail.com",
            "affiliation": "N",
            "endpointDescription": "business email address",
            "use": "HIE",
            "useDescription": "Health Information Exchange (HIE)",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "email",
            "address_1": "3939 NE Hancock St # 202",
            "city": "Portland",
            "state": "OR",
            "country_code": "US",
            "postal_code": "972125321",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Portland, OR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 25, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.