Provider Demographics
NPI:1790079101
Name:FISTE, TOD EVAN (LPC, MFT)
Entity Type:Individual
Prefix:MR
First Name:TOD
Middle Name:EVAN
Last Name:FISTE
Suffix:
Gender:M
Credentials:LPC, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 NW FLANDERS ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2060
Mailing Address - Country:US
Mailing Address - Phone:503-946-6499
Mailing Address - Fax:503-966-7948
Practice Address - Street 1:1815 NW FLANDERS ST
Practice Address - Street 2:SUITE 101
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-2060
Practice Address - Country:US
Practice Address - Phone:503-946-6499
Practice Address - Fax:503-966-7948
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-02
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC2614101YP2500X
CAMFC44519106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist