Basic Information
| Provider Information | |||||||||
| NPI: | 1538684667 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LASALLE | ||||||||
| FirstName: | LYDIA | ||||||||
| MiddleName: | JUNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ND | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PETERS | ||||||||
| OtherFirstName: | LYDIA | ||||||||
| OtherMiddleName: | JUNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | ND | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 916 S 3RD ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982734324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603365658 | ||||||||
| FaxNumber: | 3603365655 | ||||||||
| Practice Location | |||||||||
| Address1: | 916 S 3RD ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982734324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603365658 | ||||||||
| FaxNumber: | 3603365658 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2017 | ||||||||
| LastUpdateDate: | 09/12/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175F00000X | NT60796398 | WA | Y | Other Service Providers | Naturopath |
ID Information
| ID | Type | State | Issuer | Description | 2089045 | 05 | WA | MEDICAID |