Healthcare Provider Details

I. General information

NPI: 1568131308
Provider Name (Legal Business Name): MELISSA P MILLER SUDP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2021
Last Update Date: 09/07/2021
Certification Date: 09/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 N NORTHGATE WAY STE 101
SEATTLE WA
98133-9018
US

IV. Provider business mailing address

1446 MADRONA DR
SEATTLE WA
98122-3518
US

V. Phone/Fax

Practice location:
  • Phone: 206-309-3740
  • Fax:
Mailing address:
  • Phone: 206-714-8632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP00006360
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: