Healthcare Provider Details

I. General information

NPI: 1134847999
Provider Name (Legal Business Name): ANTHONY DAVID SAUCEDO III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2022
Last Update Date: 09/01/2022
Certification Date: 09/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3510 STEELHAMMER DR
CENTRALIA WA
98531-4551
US

IV. Provider business mailing address

18240 APPLEGATE ST SW
ROCHESTER WA
98579-9510
US

V. Phone/Fax

Practice location:
  • Phone: 360-623-8020
  • Fax:
Mailing address:
  • Phone: 360-448-5311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: