Healthcare Provider Details

I. General information

NPI: 1871029140
Provider Name (Legal Business Name): AUTUMN IRVINE SUDP, CAAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2017
Last Update Date: 02/28/2023
Certification Date: 02/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 W MAIN ST
KELSO WA
98626-1118
US

IV. Provider business mailing address

913 OLSON RD APT A
LONGVIEW WA
98632-5467
US

V. Phone/Fax

Practice location:
  • Phone: 360-423-2806
  • Fax: 360-423-5128
Mailing address:
  • Phone: 360-270-1158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP 60188084
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCG61313331
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: