Healthcare Provider Details

I. General information

NPI: 1477822377
Provider Name (Legal Business Name): LAKE ASPEN PROFESSIONAL GROUP PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2011
Last Update Date: 08/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1460 N 16TH AVE SUITE G
YAKIMA WA
98902-7102
US

IV. Provider business mailing address

1460 N 16TH AVE SUITE G
YAKIMA WA
98902-7102
US

V. Phone/Fax

Practice location:
  • Phone: 509-575-7750
  • Fax: 509-575-7796
Mailing address:
  • Phone: 509-575-7750
  • Fax: 509-575-7796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberMD00014780
License Number StateWA

VIII. Authorized Official

Name: DR. GEORGE VLAHAKIS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 509-575-7750