Provider Demographics
NPI:1336444900
Name:PERSSON, LANCE EDWARDS (CDPT)
Entity Type:Individual
Prefix:MR
First Name:LANCE
Middle Name:EDWARDS
Last Name:PERSSON
Suffix:
Gender:M
Credentials:CDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 E OLIVE ST
Mailing Address - Street 2:SOUND MENTAL HEALTH
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-2735
Mailing Address - Country:US
Mailing Address - Phone:206-302-2200
Mailing Address - Fax:206-302-2210
Practice Address - Street 1:2212 1ST AVE
Practice Address - Street 2:KASOTA APARTMENTS, SUITE 200
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98121-1615
Practice Address - Country:US
Practice Address - Phone:206-728-0953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-12
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60166175172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker