Provider Demographics
NPI:1215571872
Name:HART, SALLY ANN (SUDPT)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:ANN
Last Name:HART
Suffix:
Gender:F
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11910 NE 154TH ST
Mailing Address - Street 2:
Mailing Address - City:BRUSH PRAIRIE
Mailing Address - State:WA
Mailing Address - Zip Code:98606-9571
Mailing Address - Country:US
Mailing Address - Phone:360-750-9588
Mailing Address - Fax:360-750-9718
Practice Address - Street 1:11910 NE 154TH ST
Practice Address - Street 2:
Practice Address - City:BRUSH PRAIRIE
Practice Address - State:WA
Practice Address - Zip Code:98606-9571
Practice Address - Country:US
Practice Address - Phone:360-750-9588
Practice Address - Fax:360-750-9718
Is Sole Proprietor?:No
Enumeration Date:2019-11-06
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60903587101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)