Provider Demographics
NPI:1275328627
Name:BALTHAZAR-SUDA, CALENE MARIE
Entity type:Individual
Prefix:
First Name:CALENE
Middle Name:MARIE
Last Name:BALTHAZAR-SUDA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 MAHA RD
Mailing Address - Street 2:
Mailing Address - City:MAKAWAO
Mailing Address - State:HI
Mailing Address - Zip Code:96768-7416
Mailing Address - Country:US
Mailing Address - Phone:808-205-1621
Mailing Address - Fax:
Practice Address - Street 1:4570 AVERY LN SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-5608
Practice Address - Country:US
Practice Address - Phone:360-464-7935
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-14
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61622246101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health