Provider Demographics
NPI:1528344009
Name:SELF, SUE (PEER COUNSELOR)
Entity type:Individual
Prefix:MS
First Name:SUE
Middle Name:
Last Name:SELF
Suffix:
Gender:F
Credentials:PEER COUNSELOR
Other - Prefix:MS
Other - First Name:SUE
Other - Middle Name:
Other - Last Name:SELF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1305 TACOMA AVE S
Mailing Address - Street 2:SUITE#306
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-1903
Mailing Address - Country:US
Mailing Address - Phone:253-396-5000
Mailing Address - Fax:253-383-5548
Practice Address - Street 1:1302 TACOMA AVE S
Practice Address - Street 2:SUITE #306
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-1906
Practice Address - Country:US
Practice Address - Phone:253-396-5000
Practice Address - Fax:253-383-5548
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-27
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60251015251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health