Provider Demographics
NPI:1770020331
Name:EASTSIDE SOCIAL SKILLS THERAPY
Entity Type:Organization
Organization Name:EASTSIDE SOCIAL SKILLS THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:J
Authorized Official - Last Name:LATHUM
Authorized Official - Suffix:
Authorized Official - Credentials:M,ED, BCBA, AAC
Authorized Official - Phone:206-380-3009
Mailing Address - Street 1:5431 236TH PL SE
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98029-6844
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5431 236TH PL SE
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98029-6844
Practice Address - Country:US
Practice Address - Phone:509-366-5572
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-20
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health