Healthcare Provider Details

I. General information

NPI: 1740942671
Provider Name (Legal Business Name): CECILIA YACOBIAN SUDP-T
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2021
Last Update Date: 10/07/2021
Certification Date: 10/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

661 TAYLOR ST
PORT ORCHARD WA
98366-4300
US

IV. Provider business mailing address

527 RADEY ST
PORT ORCHARD WA
98366-3235
US

V. Phone/Fax

Practice location:
  • Phone: 360-337-4625
  • Fax:
Mailing address:
  • Phone: 818-554-7243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCO61135830
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: