Healthcare Provider Details

I. General information

NPI: 1184192478
Provider Name (Legal Business Name): SEAN SOTH CDP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2018
Last Update Date: 11/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 AIRPORT WAY S
SEATTLE WA
98134-1618
US

IV. Provider business mailing address

1700 AIRPORT WAY S
SEATTLE WA
98134-1618
US

V. Phone/Fax

Practice location:
  • Phone: 206-223-3644
  • Fax:
Mailing address:
  • Phone: 206-223-3644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP60235869
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberNC10053032
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: