Healthcare Provider Details

I. General information

NPI: 1497382782
Provider Name (Legal Business Name): MITCHELL ANDREW CUEBA JR. CO61037829
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2020
Last Update Date: 09/21/2022
Certification Date: 09/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 GUNNYON RD.
TOPPENISH WA
98948-9894
US

IV. Provider business mailing address

201 HIGHLAND DR
BUENA WA
98921-0139
US

V. Phone/Fax

Practice location:
  • Phone: 509-865-5121
  • Fax: 509-865-4333
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCO61037829
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: