Basic Information
| Provider Information | |||||||||
| NPI: | 1144377094 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHILDRENS HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1205 NE 88TH ST | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981153126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2069872000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1135 116TH AVE NE | ||||||||
| Address2: | |||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980044623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2069872000 | ||||||||
| FaxNumber: | 4254510214 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DE MASO | ||||||||
| AuthorizedOfficialFirstName: | DANA | ||||||||
| AuthorizedOfficialMiddleName: | LOUISE | ||||||||
| AuthorizedOfficialTitleorPosition: | MENTAL HEALTH THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 2069872000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHD. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD1600X | LH00007347 | WA | Y | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities |
No ID Information.