Basic Information
Provider Information | |||||||||
NPI: | 1588371983 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SENECA FAMILY OF AGENCIES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BEVERLY PARK ELEMENTARY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 13925 INTERURBAN AVE S STE 120 | ||||||||
Address2: |   | ||||||||
City: | TUKWILA | ||||||||
State: | WA | ||||||||
PostalCode: | 981685718 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2069480096 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1201 S 104TH ST | ||||||||
Address2: |   | ||||||||
City: | SEATTLE | ||||||||
State: | WA | ||||||||
PostalCode: | 981681549 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2069480096 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/04/2022 | ||||||||
LastUpdateDate: | 11/04/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HOBSON | ||||||||
AuthorizedOfficialFirstName: | SANDY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | QUALITY ASSURANCE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 5107255727 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SENECA FAMILY OF AGENCIES | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/04/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 200242 | 05 | WA |   | MEDICAID |