Healthcare Provider Details

I. General information

NPI: 1811708316
Provider Name (Legal Business Name): KASAUNDRA LYNN GEHLKE SUDPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2025
Last Update Date: 01/15/2025
Certification Date: 01/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2610 WETMORE AVE
EVERETT WA
98201-2927
US

IV. Provider business mailing address

2610 WETMORE AVE
EVERETT WA
98201-2927
US

V. Phone/Fax

Practice location:
  • Phone: 425-258-5270
  • Fax:
Mailing address:
  • Phone: 425-258-5270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number61521461
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: