Healthcare Provider Details

I. General information

NPI: 1033874417
Provider Name (Legal Business Name): HALEY VALENTINE JOHNSON SUDPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2021
Last Update Date: 06/06/2023
Certification Date: 06/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 SW 136TH ST
BURIEN WA
98166-1214
US

IV. Provider business mailing address

1210 SW 136TH ST
BURIEN WA
98166-1214
US

V. Phone/Fax

Practice location:
  • Phone: 206-257-6600
  • Fax:
Mailing address:
  • Phone: 206-257-6600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCO61214516
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCG61392985
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: