Provider Demographics
NPI:1427475136
Name:BELLEPHINE, JOHN (CDPT)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:BELLEPHINE
Suffix:
Gender:M
Credentials:CDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1227 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-4906
Mailing Address - Country:US
Mailing Address - Phone:360-651-2366
Mailing Address - Fax:360-653-3119
Practice Address - Street 1:1227 2ND ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-4906
Practice Address - Country:US
Practice Address - Phone:360-651-2366
Practice Address - Fax:360-653-3119
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-20
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60300104101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)