Provider Demographics
NPI:1073726485
Name:LDS FAMILY SERVICES
Entity Type:Organization
Organization Name:LDS FAMILY SERVICES
Other - Org Name:LDS FAMILY SERVICES WA SEATTLE AGENCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CBO MGR
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:POELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:855-537-1000
Mailing Address - Street 1:125 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84150-0602
Mailing Address - Country:US
Mailing Address - Phone:855-537-1000
Mailing Address - Fax:801-240-3150
Practice Address - Street 1:1201 MONSTER RD SW
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-2996
Practice Address - Country:US
Practice Address - Phone:855-537-1000
Practice Address - Fax:425-226-2531
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LDS FAMILY SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-08
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA87-0489353261QM0801X
261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)