Healthcare Provider Details

I. General information

NPI: 1053273060
Provider Name (Legal Business Name): GEETHANJALI KUPPUSAMY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2025
Last Update Date: 11/27/2025
Certification Date: 11/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20818 44TH AVE W STE 190
LYNNWOOD WA
98036-7745
US

IV. Provider business mailing address

19408 36TH AVE SE UNIT B
BOTHELL WA
98012-5284
US

V. Phone/Fax

Practice location:
  • Phone: 888-515-1793
  • Fax:
Mailing address:
  • Phone: 206-480-7372
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: