Provider Demographics
NPI:1245957018
Name:COURSEY, DALLAS R (SUDPT)
Entity type:Individual
Prefix:
First Name:DALLAS
Middle Name:R
Last Name:COURSEY
Suffix:
Gender:F
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15508 FAIR OAKS DR S
Mailing Address - Street 2:
Mailing Address - City:SPANAWAY
Mailing Address - State:WA
Mailing Address - Zip Code:98387-9051
Mailing Address - Country:US
Mailing Address - Phone:307-871-9786
Mailing Address - Fax:
Practice Address - Street 1:851 POPLAR PL S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98144-2827
Practice Address - Country:US
Practice Address - Phone:206-322-2387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-24
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYCO61361005390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program