Healthcare Provider Details

I. General information

NPI: 1427307610
Provider Name (Legal Business Name): TORE LYDERSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2012
Last Update Date: 09/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20312 42ND DR SE
BOTHELL WA
98012-7368
US

IV. Provider business mailing address

20312 42ND DR SE
BOTHELL WA
98012-7368
US

V. Phone/Fax

Practice location:
  • Phone: 425-402-4690
  • Fax:
Mailing address:
  • Phone: 425-402-4690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: