Provider Demographics
NPI:1003551805
Name:LARA LUNDQUIST, WENDY ALANA
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:ALANA
Last Name:LARA LUNDQUIST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14901 SE 272ND ST APT D304
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98042-8167
Mailing Address - Country:US
Mailing Address - Phone:425-419-9554
Mailing Address - Fax:
Practice Address - Street 1:651 STRANDER BLVD STE 105
Practice Address - Street 2:
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98188-2914
Practice Address - Country:US
Practice Address - Phone:206-393-7613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-05
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA103K00000X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
WALARALWA221MGOtherWASHINGTON STATE