Healthcare Provider Details

I. General information

NPI: 1336755206
Provider Name (Legal Business Name): DAVID ALONZO FREEMAN CO61065969
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2020
Last Update Date: 09/16/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 E CEDAR ST
SEQUIM WA
98382-3403
US

IV. Provider business mailing address

PO BOX 3175
SEQUIM WA
98382-5011
US

V. Phone/Fax

Practice location:
  • Phone: 360-681-8463
  • Fax:
Mailing address:
  • Phone: 360-681-8463
  • Fax: 360-681-8465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCO61065969
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierCO61065969
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: