Provider Demographics
NPI:1063525756
Name:WISSUSIK, DONALD WILLIAM (MA, MS)
Entity type:Individual
Prefix:MR
First Name:DONALD
Middle Name:WILLIAM
Last Name:WISSUSIK
Suffix:
Gender:M
Credentials:MA, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19185 SW 90TH AVE
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-7558
Mailing Address - Country:US
Mailing Address - Phone:503-885-7366
Mailing Address - Fax:
Practice Address - Street 1:19185 SW 90TH AVE
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-7558
Practice Address - Country:US
Practice Address - Phone:503-885-7376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT0082101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)