Healthcare Provider Details

I. General information

NPI: 1285395103
Provider Name (Legal Business Name): MARJORIE MAE SUAREZ CDPT.CO.61129031
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2022
Last Update Date: 01/04/2022
Certification Date: 01/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 N 20TH AVE
PASCO WA
99301-3393
US

IV. Provider business mailing address

1906 N 20TH AVE
PASCO WA
99301-3393
US

V. Phone/Fax

Practice location:
  • Phone: 509-792-1041
  • Fax:
Mailing address:
  • Phone: 509-792-1041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberCDPT.CO.61129031
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: