Healthcare Provider Details

I. General information

NPI: 1922680545
Provider Name (Legal Business Name): BREE ANA BLALOCK SUDP, MHP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BREE ANA BLALOCK

II. Dates (important events)

Enumeration Date: 04/23/2021
Last Update Date: 09/01/2021
Certification Date: 09/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 E 4TH PLAIN BLVD BLDG 17
VANCOUVER WA
98661-3717
US

IV. Provider business mailing address

6050 41ST AVE SW
SEATTLE WA
98136-1606
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP60417920
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCG61055353
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: