=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568959542
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PHILIP ANTHONY CONIFER SUDP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2018
-----------------------------------------------------
Last Update Date | 03/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1617 GROVE ST
-----------------------------------------------------
City | MARYSVILLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98270-4301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-522-1275
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8514 W GAGE BLVD STE G
-----------------------------------------------------
City | KENNEWICK
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99336-8108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-524-9903
-----------------------------------------------------
Fax | 888-745-2096
-----------------------------------------------------
=====================================================
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 | CP60967228
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------