Healthcare Provider Details

I. General information

NPI: 1346104122
Provider Name (Legal Business Name): VINCENT WILLIAM NISTICO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37875 JASPER LOWELL RD
JASPER OR
97438-9751
US

IV. Provider business mailing address

228 18TH ST
SPRINGFIELD OR
97477-4913
US

V. Phone/Fax

Practice location:
  • Phone: 541-747-1235
  • Fax: 541-747-4722
Mailing address:
  • Phone: 503-602-4336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: