Provider Demographics
NPI:1538684667
Name:LASALLE, LYDIA JUNE (ND)
Entity Type:Individual
Prefix:DR
First Name:LYDIA
Middle Name:JUNE
Last Name:LASALLE
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:LYDIA
Other - Middle Name:JUNE
Other - Last Name:PETERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ND
Mailing Address - Street 1:916 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-4324
Mailing Address - Country:US
Mailing Address - Phone:360-336-5658
Mailing Address - Fax:360-336-5655
Practice Address - Street 1:916 S 3RD ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-4324
Practice Address - Country:US
Practice Address - Phone:360-336-5658
Practice Address - Fax:360-336-5658
Is Sole Proprietor?:No
Enumeration Date:2017-08-09
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANT60796398175F00000X
WA175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2089045Medicaid