Basic Information
| Provider Information | |||||||||
| NPI: | 1114388683 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EASTER SEALS WASHINGTON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 NW BUCKLIN HILL RD | ||||||||
| Address2: | SUITE 215 | ||||||||
| City: | SILVERDALE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983838358 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3100 NW BUCKLIN HILL RD | ||||||||
| Address2: | SUITE 215 | ||||||||
| City: | SILVERDALE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983838358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603372222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2016 | ||||||||
| LastUpdateDate: | 03/11/2016 | ||||||||
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| AuthorizedOfficialLastName: | CLEVERDON | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3603372222 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | CG60408933 | WA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | CG60408933 | 05 | WA | MEDICAID |