Provider Demographics
NPI:1104079037
Name:BATES, WENDY ROSEANN (CDP)
Entity type:Individual
Prefix:MS
First Name:WENDY
Middle Name:ROSEANN
Last Name:BATES
Suffix:
Gender:F
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30709 82ND AVE NW
Mailing Address - Street 2:
Mailing Address - City:STANWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98292-9751
Mailing Address - Country:US
Mailing Address - Phone:360-629-0290
Mailing Address - Fax:
Practice Address - Street 1:1918 EVERETT AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-3607
Practice Address - Country:US
Practice Address - Phone:425-258-5270
Practice Address - Fax:425-258-5275
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-22
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00004316101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA00004316OtherCHEMICAL DEPENDENCY PROFESSIONAL