Healthcare Provider Details

I. General information

NPI: 1144973223
Provider Name (Legal Business Name): STACY RAEANN WIRKKALA SUDPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2022
Last Update Date: 07/01/2023
Certification Date: 06/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 W MAIN ST
KELSO WA
98626-1118
US

IV. Provider business mailing address

190 GRASSETH POSTON RD
LONGVIEW WA
98632-9147
US

V. Phone/Fax

Practice location:
  • Phone: 360-423-2806
  • Fax:
Mailing address:
  • Phone: 360-703-4251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCO61077791
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: