Healthcare Provider Details

I. General information

NPI: 1013788447
Provider Name (Legal Business Name): SHAWN MICHEAL WOITTE SUDPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2024
Last Update Date: 10/01/2025
Certification Date: 10/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5197 NW LOWER RIVER RD # ITA
VANCOUVER WA
98660-1013
US

IV. Provider business mailing address

1000 SE 160TH AVE APT EE254
VANCOUVER WA
98683-9608
US

V. Phone/Fax

Practice location:
  • Phone: 360-205-1222
  • Fax:
Mailing address:
  • Phone: 360-852-5772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberCG61448138
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: