Healthcare Provider Details

I. General information

NPI: 1386555704
Provider Name (Legal Business Name): HEATHER DAWN FORREST SUDPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 SE IRELAND ST
OAK HARBOR WA
98277-5502
US

IV. Provider business mailing address

830 SE IRELAND ST
OAK HARBOR WA
98277-5502
US

V. Phone/Fax

Practice location:
  • Phone: 360-679-7676
  • Fax: 360-682-5947
Mailing address:
  • Phone: 360-679-7676
  • Fax: 360-682-5947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDPT.CO.70115898
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: