Provider Demographics
NPI:1922892488
Name:TYSKIEWICZ, CONNOR (SUDPT)
Entity type:Individual
Prefix:
First Name:CONNOR
Middle Name:
Last Name:TYSKIEWICZ
Suffix:
Gender:F
Credentials:SUDPT
Other - Prefix:
Other - First Name:CADENCE
Other - Middle Name:
Other - Last Name:TYSKIEWICZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:235 SE 5TH ST
Mailing Address - Street 2:
Mailing Address - City:TROUTDALE
Mailing Address - State:OR
Mailing Address - Zip Code:97060-2021
Mailing Address - Country:US
Mailing Address - Phone:971-712-9210
Mailing Address - Fax:
Practice Address - Street 1:5700 E 18TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-6831
Practice Address - Country:US
Practice Address - Phone:360-313-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-08
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61621068101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)