MEDICARE: PAULETTE HYDE SUDP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	C061092443	WA

General Provider Information

NPI Number	:	1811648595
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAULETTE HYDE SUDP

Provider Business Mailing Address
First Line	:	11711 E SPRAGUE AVE STE 4
Second Line	:
City	:	SPOKANE VALLEY
State	:	WA
Zip	:	99206-6126
Country	:	US
Telephone Number	:	509-927-6838
Fax Number	:

Provider Business Practice Location Address
First Line	:	11711 E SPRAGUE AVE STE 4
Second Line	:
City	:	SPOKANE VALLEY
State	:	WA
Zip	:	99206-6126
Country	:	US
Telephone Number	:	509-927-6838
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/13/2022
Last Update Date	:	01/13/2022

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