Provider Demographics
NPI:1720457666
Name:WEISS, MICHAEL W (SUDP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:W
Last Name:WEISS
Suffix:
Gender:M
Credentials:SUDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12330 NE 8TH ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98005-3187
Mailing Address - Country:US
Mailing Address - Phone:425-454-2238
Mailing Address - Fax:
Practice Address - Street 1:12330 NE 8TH ST STE 100
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005-3187
Practice Address - Country:US
Practice Address - Phone:425-454-2238
Practice Address - Fax:425-455-8482
Is Sole Proprietor?:No
Enumeration Date:2015-09-22
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60534855101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACP60534855OtherSUDP