Provider Demographics
NPI:1851417810
Name:OPTIMALLIFE WELLNESS CENTER
Entity Type:Organization
Organization Name:OPTIMALLIFE WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LARA
Authorized Official - Middle Name:K
Authorized Official - Last Name:SYMONDS
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:425-646-2778
Mailing Address - Street 1:2320 130TH AVE NE STE 240
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98005-1718
Mailing Address - Country:US
Mailing Address - Phone:425-646-2778
Mailing Address - Fax:425-453-6377
Practice Address - Street 1:2320 130TH AVE NE STE 240
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005-1718
Practice Address - Country:US
Practice Address - Phone:425-646-2778
Practice Address - Fax:425-453-6377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 1041C0700X
WALF00001767106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
306139956OtherUBH
708715000OtherMAGELLAN
11644468OtherCAQH