=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215895875
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELLIE NICOLE HUMBLE SUDPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2026
-----------------------------------------------------
Last Update Date | 01/13/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1528 DAVIS AVE
-----------------------------------------------------
City | ENUMCLAW
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98022-3725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-678-3646
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1528 DAVIS AVE
-----------------------------------------------------
City | ENUMCLAW
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98022-3725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-678-3646
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | CO70019718
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------