Provider Demographics
NPI:1437142874
Name:PEDIATRIC SPEECH & LANG ASSOCS
Entity Type:Organization
Organization Name:PEDIATRIC SPEECH & LANG ASSOCS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SLP
Authorized Official - Prefix:MRS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:M
Authorized Official - Last Name:LESTZ
Authorized Official - Suffix:
Authorized Official - Credentials:MA,CCC-SLP
Authorized Official - Phone:425-392-2631
Mailing Address - Street 1:710 NW JUNIPER ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-2717
Mailing Address - Country:US
Mailing Address - Phone:425-392-2631
Mailing Address - Fax:425-392-4631
Practice Address - Street 1:710 NW JUNIPER ST
Practice Address - Street 2:SUITE 110
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-2717
Practice Address - Country:US
Practice Address - Phone:425-392-2631
Practice Address - Fax:425-392-4631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-30
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00001411235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7027527Medicaid