Provider Demographics
NPI:1336755206
Name:FREEMAN, DAVID ALONZO (CO61065969)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ALONZO
Last Name:FREEMAN
Suffix:
Gender:M
Credentials:CO61065969
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 3175
Mailing Address - Street 2:
Mailing Address - City:SEQUIM
Mailing Address - State:WA
Mailing Address - Zip Code:98382-5011
Mailing Address - Country:US
Mailing Address - Phone:360-681-8463
Mailing Address - Fax:360-681-8465
Practice Address - Street 1:390 E CEDAR ST
Practice Address - Street 2:
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382-3403
Practice Address - Country:US
Practice Address - Phone:360-681-8463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61065969101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACO61065969Medicaid