Healthcare Provider Details

I. General information

NPI: 1902493745
Provider Name (Legal Business Name): JOSEPH SILOS SUDPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2020
Last Update Date: 12/28/2020
Certification Date: 12/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

243613 HIGHWAY 101
PORT ANGELES WA
98363-9810
US

IV. Provider business mailing address

243613 HIGHWAY 101
PORT ANGELES WA
98363-9810
US

V. Phone/Fax

Practice location:
  • Phone: 360-452-4432
  • Fax: 360-452-4459
Mailing address:
  • Phone: 360-452-4432
  • Fax: 360-452-4459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCO61111952
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: