Healthcare Provider Details

I. General information

NPI: 1336683879
Provider Name (Legal Business Name): JOHN HORNE SUDP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2016
Last Update Date: 04/27/2022
Certification Date: 04/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1960 THOMPSON DR
SEDRO WOOLLEY WA
98284-5007
US

IV. Provider business mailing address

7440 W MARGINAL WAY S
SEATTLE WA
98108-4141
US

V. Phone/Fax

Practice location:
  • Phone: 360-856-3105
  • Fax:
Mailing address:
  • Phone: 360-856-3108
  • Fax: 360-856-3138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP 60609977
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: