Healthcare Provider Details

I. General information

NPI: 1235715889
Provider Name (Legal Business Name): THOMAS JAMES DEL RIO SUDPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2021
Last Update Date: 03/23/2021
Certification Date: 03/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514 AUBURN WAY N
AUBURN WA
98002-4335
US

IV. Provider business mailing address

514 AUBURN WAY N
AUBURN WA
98002-4335
US

V. Phone/Fax

Practice location:
  • Phone: 253-939-2211
  • Fax: 253-939-2867
Mailing address:
  • Phone: 253-939-2211
  • Fax: 253-939-2867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCO61146020
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: