Healthcare Provider Details

I. General information

NPI: 1629646245
Provider Name (Legal Business Name): NICOLE RENEE RIHANEK SUDPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2021
Last Update Date: 06/11/2021
Certification Date: 05/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11627 AIRPORT RD STE B
EVERETT WA
98204-8714
US

IV. Provider business mailing address

4325 149TH PL NE
MARYSVILLE WA
98271-8977
US

V. Phone/Fax

Practice location:
  • Phone: 425-248-4900
  • Fax:
Mailing address:
  • Phone: 425-208-6811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCO61177476
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: