Provider Demographics
NPI:1568605012
Name:JOSEPH, MICHAEL ANTHONY (SUDP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:JOSEPH
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:PO BOX 150
Mailing Address - Street 2:
Mailing Address - City:NESPELEM
Mailing Address - State:WA
Mailing Address - Zip Code:99155-0150
Mailing Address - Country:US
Mailing Address - Phone:509-634-2586
Mailing Address - Fax:509-634-2607
Practice Address - Street 1:21 COLVILLE ST.
Practice Address - Street 2:
Practice Address - City:NESPELEM
Practice Address - State:WA
Practice Address - Zip Code:99155
Practice Address - Country:US
Practice Address - Phone:509-634-2586
Practice Address - Fax:509-634-2607
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-14
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6250101YA0400X
CO116600324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)