Healthcare Provider Details

I. General information

NPI: 1669943395
Provider Name (Legal Business Name): SHIRLENE KELLY SHIRLEY SUDP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2018
Last Update Date: 10/04/2022
Certification Date: 10/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3710 N MONROE ST. RIVERSIDE RECOVERY CENTER
SPOKANE WA
99205
US

IV. Provider business mailing address

12715 E MISSION AVE
SPOKANE VALLEY WA
99216-1027
US

V. Phone/Fax

Practice location:
  • Phone: 509-328-5234
  • Fax: 509-328-2358
Mailing address:
  • Phone: 509-323-5766
  • Fax: 509-321-5472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP60081248
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: