Healthcare Provider Details

I. General information

NPI: 1073298337
Provider Name (Legal Business Name): DAMARYS MACLARA CASTRO SUDPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2023
Last Update Date: 06/15/2023
Certification Date: 06/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

723 SW 10TH ST
RENTON WA
98057-5223
US

IV. Provider business mailing address

612 W WATERMAN ST # B103
KENT WA
98032-5886
US

V. Phone/Fax

Practice location:
  • Phone: 206-461-4880
  • Fax: 206-461-6989
Mailing address:
  • Phone: 787-307-2298
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCO61450387
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: