Healthcare Provider Details

I. General information

NPI: 1164159232
Provider Name (Legal Business Name): MELISSA S HEPLER SUDP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELISSA S HOUSE

II. Dates (important events)

Enumeration Date: 08/08/2022
Last Update Date: 07/15/2025
Certification Date: 07/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

748 14TH AVE
LONGVIEW WA
98632-2315
US

IV. Provider business mailing address

PO BOX 2394
LONGVIEW WA
98632-8455
US

V. Phone/Fax

Practice location:
  • Phone: 360-200-5419
  • Fax: 844-612-6673
Mailing address:
  • Phone: 360-200-5419
  • Fax: 360-200-6736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP61628587
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: