Healthcare Provider Details

I. General information

NPI: 1770312902
Provider Name (Legal Business Name): RICHARD TIMOTHY WARREN SUDPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2024
Last Update Date: 07/27/2024
Certification Date: 07/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9930 EVERGREEN WAY STE Z150
EVERETT WA
98204-3889
US

IV. Provider business mailing address

5802 RAINIER AVE S
SEATTLE WA
98118-2706
US

V. Phone/Fax

Practice location:
  • Phone: 425-353-6425
  • Fax: 425-347-5121
Mailing address:
  • Phone: 206-732-1980
  • Fax: 206-721-3930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: