Provider Demographics
NPI:1578020707
Name:CHAN, EDITH S
Entity Type:Individual
Prefix:MRS
First Name:EDITH
Middle Name:S
Last Name:CHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:EDITH
Other - Middle Name:C
Other - Last Name:LARA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:301 S 320TH ST
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-5200
Mailing Address - Country:US
Mailing Address - Phone:253-874-7000
Mailing Address - Fax:253-874-7557
Practice Address - Street 1:301 S 320TH ST
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-5200
Practice Address - Country:US
Practice Address - Phone:253-874-7000
Practice Address - Fax:253-874-7557
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-24
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW605884161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty