Provider Demographics
NPI:1457966418
Name:SIVESIND, MARK CARL (SUDPT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:CARL
Last Name:SIVESIND
Suffix:
Gender:M
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 S VINE ST
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-7982
Mailing Address - Country:US
Mailing Address - Phone:360-452-2443
Mailing Address - Fax:360-452-2738
Practice Address - Street 1:806 S VINE ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-7982
Practice Address - Country:US
Practice Address - Phone:360-452-2443
Practice Address - Fax:360-452-2738
Is Sole Proprietor?:No
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61083927101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)