MEDICARE: STEPHANIE HOLMAN SUDP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program		WA
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	CP61634930	WA

General Provider Information

NPI Number	:	1063195352
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE HOLMAN SUDP

Provider Business Mailing Address
First Line	:	6523 CALIFORNIA AVE SW
Second Line	:	SUITE 512
City	:	SEATTLE
State	:	WA
Zip	:	98136-1833
Country	:	US
Telephone Number	:	346-298-1067
Fax Number	:

Provider Business Practice Location Address
First Line	:	3272 CALIFORNIA AVE SW
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98116-3375
Country	:	US
Telephone Number	:	346-298-1067
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/11/2023
Last Update Date	:	03/10/2026

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