Healthcare Provider Details

I. General information

NPI: 1235517814
Provider Name (Legal Business Name): KIDST S TASISA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2015
Last Update Date: 02/17/2023
Certification Date: 02/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 MLK JR WAY S
SEATTLE WA
98144-4801
US

IV. Provider business mailing address

2103 S ATLANTIC ST
SEATTLE WA
98144-3615
US

V. Phone/Fax

Practice location:
  • Phone: 206-322-7676
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberCG60562330
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: