Healthcare Provider Details

I. General information

NPI: 1699472019
Provider Name (Legal Business Name): GINA LOUISE MARCHELLO SUDPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2023
Last Update Date: 02/15/2023
Certification Date: 02/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

628 S COWLEY ST
SPOKANE WA
99202-1377
US

IV. Provider business mailing address

5709 N AUDUBON ST
SPOKANE WA
99205-7220
US

V. Phone/Fax

Practice location:
  • Phone: 509-624-3227
  • Fax:
Mailing address:
  • Phone: 424-750-6058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: