Provider Demographics
NPI:1740878818
Name:PURCELLA, ANTHONY XAVIOR
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:XAVIOR
Last Name:PURCELLA
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 1:814 CRANE BLVD
Mailing Address - Street 2:
Mailing Address - City:BURNS
Mailing Address - State:OR
Mailing Address - Zip Code:97720-2115
Mailing Address - Country:US
Mailing Address - Phone:541-413-1352
Mailing Address - Fax:
Practice Address - Street 1:348 W ADAMS ST
Practice Address - Street 2:
Practice Address - City:BURNS
Practice Address - State:OR
Practice Address - Zip Code:97720-1710
Practice Address - Country:US
Practice Address - Phone:541-573-8376
Practice Address - Fax:541-573-8378
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-05
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)