Healthcare Provider Details

I. General information

NPI: 1538003421
Provider Name (Legal Business Name): GENESIS LATHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LEO LATHAM

II. Dates (important events)

Enumeration Date: 04/20/2026
Last Update Date: 04/20/2026
Certification Date: 04/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33314 SE 42ND ST
FALL CITY WA
98024-8747
US

IV. Provider business mailing address

2323 S HOLGATE ST
SEATTLE WA
98144-4613
US

V. Phone/Fax

Practice location:
  • Phone: 425-831-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: