Healthcare Provider Details

I. General information

NPI: 1780036004
Provider Name (Legal Business Name): SUZANNA SHEPHERD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2016
Last Update Date: 04/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22026 20TH AVE SE STE 101 CANYON PARK TREATMENT SOLUTIONS
BOTHELL WA
98021-4449
US

IV. Provider business mailing address

22026 20TH AVE SE STE 101 CANYON PARK TREATMENT SOLUTIONS
BOTHELL WA
98021-4449
US

V. Phone/Fax

Practice location:
  • Phone: 425-672-7293
  • Fax: 425-329-4640
Mailing address:
  • Phone: 425-672-7293
  • Fax: 425-329-4640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number60656742
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCO60656742
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierCO60656742
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: