Provider Demographics
NPI:1265553382
Name:LAKESIDE SPEECH LANGUAGE AND LEARNING, LLC
Entity type:Organization
Organization Name:LAKESIDE SPEECH LANGUAGE AND LEARNING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:STACHELSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MS,CCC-SLP
Authorized Official - Phone:360-303-9130
Mailing Address - Street 1:7125 SILENT CREEK AVE SE
Mailing Address - Street 2:
Mailing Address - City:SNOQUALMIE
Mailing Address - State:WA
Mailing Address - Zip Code:98065
Mailing Address - Country:US
Mailing Address - Phone:360-303-7130
Mailing Address - Fax:206-333-0031
Practice Address - Street 1:7829 CENTER BLVD STE 223
Practice Address - Street 2:
Practice Address - City:SNOQUALMIE
Practice Address - State:WA
Practice Address - Zip Code:98065
Practice Address - Country:US
Practice Address - Phone:360-303-9130
Practice Address - Fax:206-333-0031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00003914235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty