Basic Information
| Provider Information | |||||||||
| NPI: | 1386011765 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DE LA ROSA | ||||||||
| FirstName: | BETSY | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | M.A., CFY-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3600 LIND AVE SW | ||||||||
| Address2: | SUITE 100 ATTN CREDENTIALING | ||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980574970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256902715 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3600 LIND AVE SW STE 160 | ||||||||
| Address2: | |||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980574934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256903513 | ||||||||
| FaxNumber: | 4256909513 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2015 | ||||||||
| LastUpdateDate: | 05/12/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | LL61033853 | WA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 9560 | MN | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 215572 | 05 | WA | MEDICAID |