Provider Demographics
NPI:1700411758
Name:STETSYSHIN, EKATERINA (SUDP-T)
Entity Type:Individual
Prefix:MRS
First Name:EKATERINA
Middle Name:
Last Name:STETSYSHIN
Suffix:
Gender:F
Credentials:SUDP-T
Other - Prefix:MRS
Other - First Name:KATYA
Other - Middle Name:
Other - Last Name:STETSYSHIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:SUDP-T
Mailing Address - Street 1:13280 NE 183RD ST
Mailing Address - Street 2:
Mailing Address - City:WOODINVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98072-8712
Mailing Address - Country:US
Mailing Address - Phone:415-407-9129
Mailing Address - Fax:
Practice Address - Street 1:16715 AURORA AVE N STE 102
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98133-5310
Practice Address - Country:US
Practice Address - Phone:206-323-0930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-10
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60979973101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACO60979973OtherDEPARTMENT OF HEALTH