Provider Demographics
NPI:1386790020
Name:SOSA, ANTONIO ZAVALA (ATA)
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:ZAVALA
Last Name:SOSA
Suffix:
Gender:M
Credentials:ATA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 34703
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1703
Mailing Address - Country:US
Mailing Address - Phone:206-764-0112
Mailing Address - Fax:206-764-0489
Practice Address - Street 1:2500 E COLLEGE WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-5862
Practice Address - Country:US
Practice Address - Phone:360-428-8912
Practice Address - Fax:360-424-6288
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00004425101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1992718Medicaid