Provider Demographics
NPI:1922497643
Name:SULLATESKEE-RINCON, BROOKE (LH)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:SULLATESKEE-RINCON
Suffix:
Gender:F
Credentials:LH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13400 NE 20TH ST STE 47
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98005-2026
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2592 KWINA RD
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-9278
Practice Address - Country:US
Practice Address - Phone:360-384-0464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-19
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH61324079101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA203571800Medicaid