Provider Demographics
NPI:1972278158
Name:SISTO, PURCELL (CADC I)
Entity Type:Individual
Prefix:
First Name:PURCELL
Middle Name:
Last Name:SISTO
Suffix:
Gender:M
Credentials:CADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 17818
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-7818
Mailing Address - Country:US
Mailing Address - Phone:503-363-2021
Mailing Address - Fax:
Practice Address - Street 1:565 UNION ST NE STE 105
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-2416
Practice Address - Country:US
Practice Address - Phone:503-540-5554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-10
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT-20-506101YA0400X
OR22-05-10407101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)