=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245919794
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOPE HOLDERS KETCHIKAN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2023
-----------------------------------------------------
Last Update Date | 12/30/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3175 JACKSON HEIGHTS ST
-----------------------------------------------------
City | KETCHIKAN
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99901-5782
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-617-1378
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3175 JACKSON HEIGHTS ST
-----------------------------------------------------
City | KETCHIKAN
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99901-5782
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-617-1378
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE CLINICAL DIRECTOR
-----------------------------------------------------
Name | MR. JOHN DAVID SUNDEEN
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 907-821-4674
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 175T00000X
-----------------------------------------------------
Taxonomy Name | Peer Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------