Healthcare Provider Details

I. General information

NPI: 1851110605
Provider Name (Legal Business Name): MISTY ANN BJORLAND-SPENCER SUDPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2024
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 SUMMIT AVE
EVERETT WA
98201-3309
US

IV. Provider business mailing address

2601 SUMMIT AVE
EVERETT WA
98201-3309
US

V. Phone/Fax

Practice location:
  • Phone: 425-258-2407
  • Fax:
Mailing address:
  • Phone: 425-258-2407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number91-0897867
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number910897867
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCO60594426
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: