Provider Demographics
NPI:1821205808
Name:SOMDAHL, GARY (CDP)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:SOMDAHL
Suffix:
Gender:M
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5503 ASPEN DR
Mailing Address - Street 2:
Mailing Address - City:WEST RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99353-7705
Mailing Address - Country:US
Mailing Address - Phone:509-942-1624
Mailing Address - Fax:
Practice Address - Street 1:1305 MANSFIELD ST
Practice Address - Street 2:SUITE 5
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3588
Practice Address - Country:US
Practice Address - Phone:509-942-1624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00001001101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)