Provider Demographics
NPI:1144386236
Name:EAST LAKE PSYCHOLOGICAL SERVICES, PS
Entity Type:Organization
Organization Name:EAST LAKE PSYCHOLOGICAL SERVICES, PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:YIE -WEN
Authorized Official - Middle Name:YUAN
Authorized Official - Last Name:KUAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:425-785-5887
Mailing Address - Street 1:4026 NE 55TH ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-2262
Mailing Address - Country:US
Mailing Address - Phone:425-785-5887
Mailing Address - Fax:
Practice Address - Street 1:4026 NE 55TH ST
Practice Address - Street 2:SUITE D
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-2262
Practice Address - Country:US
Practice Address - Phone:425-785-5887
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-31
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY 1728103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty