Provider Demographics
NPI:1104486331
Name:FORTSON, ANABEL (SUDPT)
Entity type:Individual
Prefix:
First Name:ANABEL
Middle Name:
Last Name:FORTSON
Suffix:
Gender:
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12850 LALA COVE LN SE
Mailing Address - Street 2:
Mailing Address - City:OLALLA
Mailing Address - State:WA
Mailing Address - Zip Code:98359-9664
Mailing Address - Country:US
Mailing Address - Phone:253-857-6201
Mailing Address - Fax:253-857-6201
Practice Address - Street 1:12850 LALA COVE LN SE
Practice Address - Street 2:
Practice Address - City:OLALLA
Practice Address - State:WA
Practice Address - Zip Code:98359-9664
Practice Address - Country:US
Practice Address - Phone:253-857-6201
Practice Address - Fax:253-857-6201
Is Sole Proprietor?:No
Enumeration Date:2019-06-19
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAC061110668101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)