Healthcare Provider Details

I. General information

NPI: 1679302699
Provider Name (Legal Business Name): VICTORIA LYNN HAFOKA SUDPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: VICTORIA LYNN REYNOLDS

II. Dates (important events)

Enumeration Date: 07/29/2024
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 E 4TH PLAIN BLVD
VANCOUVER WA
98661-3713
US

IV. Provider business mailing address

51 SIEVERS RD
WASHOUGAL WA
98671-7225
US

V. Phone/Fax

Practice location:
  • Phone: 360-397-8246
  • Fax:
Mailing address:
  • Phone: 801-949-2922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCO61561982
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: