Basic Information
| Provider Information | |||||||||
| NPI: | 1295195394 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OLYMPIC PENINSULA AUTISM CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | EASTER SEALS AUTISM CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1331 ELIZABETH AVE | ||||||||
| Address2: | |||||||||
| City: | BREMERTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983371730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4158270698 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3100 NW BUCKLIN HILL RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | SILVERDALE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983838359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603372222 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2016 | ||||||||
| LastUpdateDate: | 03/02/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GIRTLER | ||||||||
| AuthorizedOfficialFirstName: | CHELSEA | ||||||||
| AuthorizedOfficialMiddleName: | DAYNE | ||||||||
| AuthorizedOfficialTitleorPosition: | RBT | ||||||||
| AuthorizedOfficialTelephone: | 4158270698 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MISS | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CG | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | CG | WA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | CG | 05 | WA | MEDICAID |