Healthcare Provider Details

I. General information

NPI: 1275354094
Provider Name (Legal Business Name): SASCHA RAMON STOKLEY SUDPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2024
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 S 3RD ST
SHELTON WA
98584-2255
US

IV. Provider business mailing address

235 S 3RD ST
SHELTON WA
98584-2255
US

V. Phone/Fax

Practice location:
  • Phone: 360-426-0890
  • Fax: 360-426-4688
Mailing address:
  • Phone: 360-426-0890
  • Fax: 360-426-4688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCO61577540
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: