Healthcare Provider Details

I. General information

NPI: 1255947982
Provider Name (Legal Business Name): DOUGLAS ANDREW STENCHEVER SUDP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2020
Last Update Date: 09/18/2020
Certification Date: 09/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6334 LITTLEROCK RD SW
TUMWATER WA
98512-7332
US

IV. Provider business mailing address

7711 MANNING LN NW
OLYMPIA WA
98502-9372
US

V. Phone/Fax

Practice location:
  • Phone: 360-704-7590
  • Fax:
Mailing address:
  • Phone: 360-584-8817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number00001197
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: