Healthcare Provider Details

I. General information

NPI: 1679025019
Provider Name (Legal Business Name): LESLIE STANYER SUDP, LMHC, WSCGC-1
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2016
Last Update Date: 08/20/2025
Certification Date: 08/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

945 11TH AVE
LONGVIEW WA
98632-2555
US

IV. Provider business mailing address

945 11TH AVE
LONGVIEW WA
98632-2555
US

V. Phone/Fax

Practice location:
  • Phone: 360-232-3605
  • Fax: 360-636-7372
Mailing address:
  • Phone: 360-232-3605
  • Fax: 360-636-7372

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP60688878
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH61677233
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: