Healthcare Provider Details

I. General information

NPI: 1053775072
Provider Name (Legal Business Name): ELIZABETH BRYAN SUDP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH MARY CRINER SUDP

II. Dates (important events)

Enumeration Date: 04/06/2016
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 W HERON ST
ABERDEEN WA
98520-6022
US

IV. Provider business mailing address

138 S 1ST ST STE 6
MONTESANO WA
98563-3623
US

V. Phone/Fax

Practice location:
  • Phone: 564-544-1950
  • Fax: 564-544-1938
Mailing address:
  • Phone: 360-964-4142
  • Fax: 360-964-4143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP60494027
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: