Provider Demographics
NPI:1295199743
Name:TEDROW, SIMON S (SUDP)
Entity Type:Individual
Prefix:
First Name:SIMON
Middle Name:S
Last Name:TEDROW
Suffix:
Gender:M
Credentials:SUDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4211 SINAI CT
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-8243
Mailing Address - Country:US
Mailing Address - Phone:877-522-1275
Mailing Address - Fax:
Practice Address - Street 1:8514 W GAGE BLVD STE G
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-8108
Practice Address - Country:US
Practice Address - Phone:877-522-1275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-11
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
WACP60215848101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health