Basic Information
| Provider Information | |||||||||
| NPI: | 1588802953 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKESIDE CENTER FOR AUTISM, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5150 VILLAGE PARK DR SE | ||||||||
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| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980066652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256570620 | ||||||||
| FaxNumber: | 4255028425 | ||||||||
| Practice Location | |||||||||
| Address1: | 5150 VILLAGE PARK DR SE | ||||||||
| Address2: | |||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980066652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256570620 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2009 | ||||||||
| LastUpdateDate: | 11/15/2021 | ||||||||
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| AuthorizedOfficialLastName: | STACHELSKI | ||||||||
| AuthorizedOfficialFirstName: | DAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4256570620 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MS CCC-SLP | ||||||||
| NPICertificationDate: | 11/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | LL00003914 | WA | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.