Healthcare Provider Details

I. General information

NPI: 1710630082
Provider Name (Legal Business Name): STEPHANIE C TIDHOLM SUDPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2022
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2133 3RD AVE
SEATTLE WA
98121-2385
US

IV. Provider business mailing address

2133 3RD AVE
SEATTLE WA
98121-2385
US

V. Phone/Fax

Practice location:
  • Phone: 206-223-1482
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number101YA0400X
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: