Healthcare Provider Details

I. General information

NPI: 1285526269
Provider Name (Legal Business Name): SKYLA RAE ALYCE HENRY SUDPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2025
Last Update Date: 07/16/2025
Certification Date: 07/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6330 31ST AVE NE STE 101
TULALIP WA
98271-7423
US

IV. Provider business mailing address

4316 SUNRISE LOOP RD
TULALIP WA
98271-2100
US

V. Phone/Fax

Practice location:
  • Phone: 360-716-2200
  • Fax:
Mailing address:
  • Phone: 360-502-6428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCO61682932
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: