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General NPI Number Information
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NPI Number | 1225738859
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Entity Type | Individual
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Provider Name | HEATHER ANN IVY SUDP III
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Gender | Female
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Dates
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Enumeration Date | 03/02/2023
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Last Update Date | 07/08/2025
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Provider Practice Location Address
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Address Line | 1415 CENTER ST
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City | TACOMA
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State | WA
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Zip | 98409-8210
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Country | US
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Telephone | 253-280-9860
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Fax | 253-280-9870
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Provider Business Mailing Address
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Address Line | 9650 15TH AVE SW
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City | SEATTLE
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State | WA
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Zip | 98106-2576
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Country | US
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Telephone | 206-965-1055
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Fax | 206-965-1032
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | CP61678744
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number | CO61296221
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License Number State | WA
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