Provider Demographics
NPI:1578127312
Name:EASTERN, DEENA JO (MS)
Entity Type:Individual
Prefix:
First Name:DEENA
Middle Name:JO
Last Name:EASTERN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:DEENA
Other - Middle Name:JO
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:5667 176TH PL SE
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98006-5936
Mailing Address - Country:US
Mailing Address - Phone:425-941-1450
Mailing Address - Fax:
Practice Address - Street 1:5667 176TH PL SE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98006-5936
Practice Address - Country:US
Practice Address - Phone:425-941-1450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-26
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00004456101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty