Provider Demographics
NPI:1952633737
Name:EASTSIDE BEHAVIORAL MEDICINE
Entity Type:Organization
Organization Name:EASTSIDE BEHAVIORAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:CAPETILLO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:425-454-3110
Mailing Address - Street 1:1601 114TH AVE SE
Mailing Address - Street 2:SUITE 145
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-6950
Mailing Address - Country:US
Mailing Address - Phone:425-454-3110
Mailing Address - Fax:425-283-0486
Practice Address - Street 1:1601 114TH AVE SE
Practice Address - Street 2:SUITE 145
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-6950
Practice Address - Country:US
Practice Address - Phone:425-454-3110
Practice Address - Fax:425-283-0486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-04
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602-967-118103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0240031OtherLABOR AND INDUSTRIES/MASON
WA0221560OtherLABOR AND INDUSTRIES/CAPETILLO
WA602967118OtherUBI
WA0221560OtherLABOR AND INDUSTRIES/CAPETILLO
WAG8875978Medicare PIN