Provider Demographics
NPI:1508111766
Name:LATHUM, PENNY JANE (MED, BCBA)
Entity Type:Individual
Prefix:MRS
First Name:PENNY
Middle Name:JANE
Last Name:LATHUM
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:PENNY
Other - Middle Name:JANE
Other - Last Name:WADE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED, BCBA
Mailing Address - Street 1:5436 232ND AVE SE
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98029
Mailing Address - Country:US
Mailing Address - Phone:206-380-3009
Mailing Address - Fax:425-837-1982
Practice Address - Street 1:3849 KLAHANIE DR SE APT 1-101
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98029-5720
Practice Address - Country:US
Practice Address - Phone:206-380-3009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-13
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-10-7087103K00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst