Provider Demographics
NPI:1457072522
Name:NGUYEN, PHUC NGOC (SUDPT)
Entity Type:Individual
Prefix:
First Name:PHUC
Middle Name:NGOC
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3914 NE 10TH ST
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98056-3585
Mailing Address - Country:US
Mailing Address - Phone:206-483-9729
Mailing Address - Fax:
Practice Address - Street 1:9100 BRIDGEPORT WAY SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-2427
Practice Address - Country:US
Practice Address - Phone:253-302-3826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-07
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61354051101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)