Healthcare Provider Details

I. General information

NPI: 1093356982
Provider Name (Legal Business Name): RAMONA Y ARNE SUDP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RAMONA Y ARNE SUDP

II. Dates (important events)

Enumeration Date: 10/02/2019
Last Update Date: 04/27/2021
Certification Date: 04/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2107 1ST ST
EUREKA CA
95501-0840
US

IV. Provider business mailing address

3435 CHURCH ST
FORTUNA CA
95540-3312
US

V. Phone/Fax

Practice location:
  • Phone: 707-273-6395
  • Fax:
Mailing address:
  • Phone: 253-439-7645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number60116511
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP60116511
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: