Healthcare Provider Details

I. General information

NPI: 1992411789
Provider Name (Legal Business Name): BRANDON ANTHONY MCDONALD SUDPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2023
Last Update Date: 01/25/2023
Certification Date: 01/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12715 E MISSION AVE
SPOKANE VALLEY WA
99216-1027
US

IV. Provider business mailing address

3315 E EUCLID AVE
SPOKANE WA
99217-6938
US

V. Phone/Fax

Practice location:
  • Phone: 509-232-5766
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCO61241154
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: