Provider Demographics
NPI:1114388683
Name:EASTER SEALS WASHINGTON
Entity Type:Organization
Organization Name:EASTER SEALS WASHINGTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEVERDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-337-2222
Mailing Address - Street 1:3100 NW BUCKLIN HILL RD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-8358
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3100 NW BUCKLIN HILL RD
Practice Address - Street 2:SUITE 215
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-8358
Practice Address - Country:US
Practice Address - Phone:360-337-2222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-11
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60408933251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACG60408933Medicaid