Provider Demographics
NPI:1003515636
Name:CRISCUOLO, ALEXANDER
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:CRISCUOLO
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 1:450 NW SKYLINE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-6800
Mailing Address - Country:US
Mailing Address - Phone:503-296-9571
Mailing Address - Fax:
Practice Address - Street 1:18765 SW BOONES FERRY RD STE 100
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-8607
Practice Address - Country:US
Practice Address - Phone:503-612-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-02
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician