Provider Demographics
NPI:1225747538
Name:TOMASELLO, KYLE ANDREW (CADCR)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:ANDREW
Last Name:TOMASELLO
Suffix:
Gender:M
Credentials:CADCR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 FERRY ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3773
Mailing Address - Country:US
Mailing Address - Phone:503-363-6103
Mailing Address - Fax:
Practice Address - Street 1:525 FERRY ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3773
Practice Address - Country:US
Practice Address - Phone:503-363-6103
Practice Address - Fax:503-363-0833
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-16
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT-22-2128101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)